Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range10004 1/1/2019 N10005 1/1/2019 N10006 1/1/2019 N10007 1/1/2019 N10008 1/1/2019 N10009 1/1/2019 N10010 1/1/2019 N10021 7/1/2004 N10030 1/1/2014 N10040 1/1/2006 N10060 1/1/2006 N10061 7/1/2004 N10080 7/1/2004 N10081 7/1/2004 N10120 7/1/2004 N10121 7/1/2004 N10140 7/1/2004 N10160 7/1/2004 N10180 7/1/2004 N11000 7/1/2004 N11001 1/1/2006 N11010 7/1/2004 N11011 7/1/2004 N11012 7/1/2004 N11042 7/1/2004 N11043 7/1/2004 N11044 7/1/2004 N11045 1/1/2011 N11046 1/1/2011 N11047 1/1/2011 N11055 7/1/2004 N11056 7/1/2004 N11057 7/1/2004 N11102 1/1/2019 N11103 1/1/2019 N11104 1/1/2019 N11105 1/1/2019 N11106 1/1/2019 N11107 1/1/2019 N11200 1/1/2006 N11201 1/1/2006 N11300 1/1/2006 N11301 1/1/2006 N11302 1/1/2006 N11303 1/1/2006 N11305 1/1/2006 N11306 1/1/2006 N11307 1/1/2006 N11308 1/1/2006 N11310 1/1/2006 N11311 1/1/2006 N11312 1/1/2006 N11313 1/1/2006 N

Page 1 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range11400 1/1/2006 N11401 1/1/2006 N11402 1/1/2006 N11403 1/1/2006 N11404 1/1/2006 N11406 1/1/2006 N11420 1/1/2006 N11421 1/1/2006 N11422 1/1/2006 N11423 1/1/2006 N11424 1/1/2006 N11426 1/1/2006 N11440 1/1/2006 N11441 1/1/2006 N11442 7/1/2004 N11443 7/1/2004 N11444 7/1/2004 N11446 7/1/2004 N11450 7/1/2004 N11451 7/1/2004 N11462 7/1/2004 N11463 7/1/2004 N11470 7/1/2004 N11471 7/1/2004 N11603 7/1/2004 N11604 7/1/2004 N11606 7/1/2004 N11622 7/1/2004 N11623 7/1/2004 N11624 7/1/2004 N11626 7/1/2004 N11640 7/1/2004 N11641 7/1/2004 N11642 7/1/2004 N11643 7/1/2004 N11644 7/1/2004 N11646 7/1/2004 N11760 7/1/2004 N11762 7/1/2004 N11770 7/1/2004 N11771 7/1/2004 N11772 7/1/2004 N11960 7/1/2004 N11970 7/1/2004 N11971 7/1/2004 N11976 1/1/2006 Y 10 through 60 years11980 1/1/2006 N11981 7/1/2004 N11982 7/1/2004 N11983 7/1/2004 N12001 1/1/2006 N12002 1/1/2006 N12004 7/1/2004 N12005 7/1/2004 N

Page 2 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range12006 7/1/2004 N12007 7/1/2004 N12011 1/1/2006 N12013 7/1/2004 N12014 7/1/2004 N12015 7/1/2004 N12016 7/1/2004 N12017 7/1/2004 N12018 7/1/2004 N12020 7/1/2004 N12021 7/1/2004 N12031 7/1/2004 N12032 7/1/2004 N12034 7/1/2004 N12035 7/1/2004 N12036 7/1/2004 N12037 7/1/2004 N12041 1/1/2006 N12042 7/1/2004 N12044 7/1/2004 N12045 7/1/2004 N12046 7/1/2004 N12047 7/1/2004 N12051 1/1/2006 N12052 7/1/2004 N12053 7/1/2004 N12054 7/1/2004 N12055 7/1/2004 N12056 7/1/2004 N12057 7/1/2004 N13100 1/1/2006 N13101 7/1/2004 N13120 7/1/2004 N13121 7/1/2004 N13131 7/1/2004 N13132 7/1/2004 N13133 7/1/2004 N13151 7/1/2004 N13152 7/1/2004 N13160 7/1/2004 N14000 7/1/2004 N14001 7/1/2004 N14020 7/1/2004 N14021 7/1/2004 N14040 7/1/2004 N14041 7/1/2004 N14060 7/1/2004 N14061 7/1/2004 N14350 7/1/2004 N15002 1/1/2007 N15003 1/1/2007 N15004 1/1/2007 N15005 1/1/2007 N15040 1/1/2006 N

Page 3 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range15050 7/1/2004 N15100 7/1/2004 N15101 1/1/2006 N15110 1/1/2006 N15111 1/1/2006 N15115 1/1/2006 N15116 1/1/2006 N15120 7/1/2004 N15121 1/1/2006 N15130 1/1/2006 N15131 1/1/2006 N15135 1/1/2006 N15136 1/1/2006 N15150 1/1/2006 N15151 1/1/2006 N15152 1/1/2006 N15155 1/1/2006 N15156 1/1/2006 N15157 1/1/2006 N15200 7/1/2004 N15201 1/1/2006 N15220 7/1/2004 N15221 1/1/2006 N15240 7/1/2004 N15241 1/1/2006 N15260 7/1/2004 N15261 1/1/2006 N15271 1/1/2012 N15272 1/1/2012 N15273 1/1/2012 N15274 1/1/2012 N15275 1/1/2012 N15276 1/1/2012 N15277 1/1/2012 N15278 1/1/2012 N15570 7/1/2004 N15572 7/1/2004 N15574 7/1/2004 N15576 7/1/2004 N15600 7/1/2004 N15610 7/1/2004 N15620 7/1/2004 N15630 7/1/2004 N15650 7/1/2004 N15731 1/1/2007 N15733 1/1/2018 N15734 7/1/2004 N15736 7/1/2004 N15738 7/1/2004 N15740 7/1/2004 N15750 7/1/2004 N15760 7/1/2004 N15770 7/1/2004 N15777 1/1/2012 N

Page 4 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range15819 7/1/2004 N15820 7/1/2004 N15821 7/1/2004 N15822 7/1/2004 N15823 7/1/2004 N15830 1/1/2007 N15832 1/1/2006 N15833 1/1/2006 N15834 1/1/2006 N15835 1/1/2006 N15836 1/1/2006 N15837 1/1/2006 N15838 1/1/2006 N15839 1/1/2006 N15840 7/1/2004 N15841 7/1/2004 N15842 7/1/2004 N15845 7/1/2004 N15847 1/1/2007 N15850 7/1/2004 N15851 7/1/2004 N15852 7/1/2004 N15876 1/1/2006 N15877 1/1/2006 N15878 1/1/2006 N15879 1/1/2006 N15920 7/1/2004 N15922 7/1/2004 N15931 7/1/2004 N15933 7/1/2004 N15934 7/1/2004 N15935 7/1/2004 N15936 7/1/2004 N15937 7/1/2004 N15940 7/1/2004 N15941 7/1/2004 N15944 7/1/2004 N15945 7/1/2004 N15946 7/1/2004 N15950 7/1/2004 N15951 7/1/2004 N15952 7/1/2004 N15953 7/1/2004 N15956 7/1/2004 N15958 7/1/2004 N15999 7/1/2004 N16020 7/1/2004 N16025 7/1/2004 N16030 7/1/2004 N16035 7/1/2004 N17106 7/1/2004 N17107 7/1/2004 N17108 7/1/2004 N17260 7/1/2004 N

Page 5 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range17261 7/1/2004 N17262 7/1/2004 N17263 7/1/2004 N17264 7/1/2004 N17266 7/1/2004 N17270 7/1/2004 N17271 7/1/2004 N17272 7/1/2004 N17273 7/1/2004 N17274 7/1/2004 N17276 7/1/2004 N17280 7/1/2004 N17281 7/1/2004 N17282 7/1/2004 N17283 7/1/2004 N17284 7/1/2004 N17286 7/1/2004 N17311 1/1/2007 N17312 1/1/2007 N17313 1/1/2007 N17314 1/1/2007 N17315 1/1/2007 N19020 7/1/2004 N19030 7/1/2004 N19081 1/1/2014 N19082 1/1/2014 N19083 1/1/2014 N19084 1/1/2014 N19085 1/1/2014 N19086 1/1/2014 N19100 7/1/2004 N19101 7/1/2004 N19105 1/1/2007 N19110 7/1/2004 N19112 7/1/2004 N19120 7/1/2004 N19125 7/1/2004 N19126 1/1/2006 N19260 1/1/2006 N19296 1/1/2005 N19298 1/1/2005 N19300 1/1/2007 N19301 1/1/2007 N19302 1/1/2007 N19303 1/1/2007 N19304 1/1/2007 N19307 1/1/2007 N19316 1/1/2006 N19318 7/1/2004 N19324 1/1/2006 N19325 1/1/2006 N19328 7/1/2004 N19330 7/1/2004 N19340 7/1/2004 N

Page 6 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range19342 7/1/2004 N19350 7/1/2004 N19355 1/1/2006 N19357 7/1/2004 N19370 7/1/2004 N19371 7/1/2004 N19380 7/1/2004 N19499 1/1/2006 N20100 7/1/2004 N20101 7/1/2004 N20102 7/1/2004 N20103 7/1/2004 N20150 7/1/2004 N20200 7/1/2004 N20205 7/1/2004 N20206 7/1/2004 N20220 7/1/2004 N20225 7/1/2004 N20240 7/1/2004 N20245 7/1/2004 N20250 7/1/2004 N20251 7/1/2004 N20500 7/1/2004 N20501 7/1/2004 N20520 7/1/2004 N20525 7/1/2004 N20610 7/1/2004 N20611 1/1/2015 N20615 7/1/2004 N20650 7/1/2004 N20660 7/1/2004 N20662 7/1/2004 N20663 7/1/2004 N20665 7/1/2004 N20670 7/1/2004 N20680 7/1/2004 N20690 7/1/2004 N20692 7/1/2004 N20693 7/1/2004 N20694 7/1/2004 N20696 1/1/2009 N20697 1/1/2009 N20900 1/1/2006 N20902 1/1/2006 N20910 1/1/2006 N20912 7/1/2004 N20920 1/1/2006 N20922 1/1/2006 N20924 7/1/2004 N20926 1/1/2006 N20950 7/1/2004 N20972 7/1/2004 N20973 7/1/2004 N20975 7/1/2004 N

Page 7 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range20982 7/1/2004 N20983 1/1/2015 N20985 1/1/2008 N21010 7/1/2004 N21011 1/1/2010 N21012 1/1/2010 N21013 1/1/2010 N21014 1/1/2010 N21015 1/1/2006 N21016 1/1/2010 N21025 7/1/2004 N21026 7/1/2004 N21029 7/1/2004 N21030 7/1/2004 N21031 7/1/2004 N21032 7/1/2004 N21034 1/1/2006 N21040 7/1/2004 N21044 1/1/2006 N21046 7/1/2004 N21047 1/1/2006 N21048 1/1/2006 N21049 1/1/2006 N21050 7/1/2004 N21060 7/1/2004 N21070 7/1/2004 N21073 1/1/2008 N21100 7/1/2004 N21110 1/1/2006 N21116 7/1/2004 N21120 7/1/2004 N21121 7/1/2004 N21122 7/1/2004 N21123 7/1/2004 N21125 7/1/2004 N21127 7/1/2004 N21137 7/1/2004 N21138 7/1/2004 N21139 7/1/2004 N21150 1/1/2006 N21172 1/1/2006 N21175 1/1/2006 N21181 7/1/2004 N21193 1/1/2006 N21195 1/1/2006 N21198 7/1/2004 N21199 7/1/2004 N21206 7/1/2004 N21208 7/1/2004 N21209 7/1/2004 N21210 7/1/2004 N21215 7/1/2004 N21230 1/1/2006 N21235 7/1/2004 N

Page 8 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range21240 7/1/2004 N21242 7/1/2004 N21243 1/1/2006 N21244 1/1/2006 N21245 7/1/2004 N21246 7/1/2004 N21248 1/1/2006 N21249 1/1/2006 N21256 1/1/2006 N21260 1/1/2006 N21261 1/1/2006 N21263 1/1/2006 N21267 1/1/2006 N21270 1/1/2006 N21275 1/1/2006 N21280 7/1/2004 N21282 7/1/2004 N21295 7/1/2004 N21296 7/1/2004 N21299 7/1/2004 N21310 1/1/2006 N21315 1/1/2006 N21320 7/1/2004 N21325 7/1/2004 N21330 7/1/2004 N21335 7/1/2004 N21336 7/1/2004 N21337 7/1/2004 N21338 7/1/2004 N21339 7/1/2004 N21340 7/1/2004 N21345 1/1/2006 N21346 1/1/2006 N21355 7/1/2004 N21356 1/1/2006 N21360 1/1/2006 N21365 1/1/2006 N21385 1/1/2006 N21386 1/1/2006 N21387 1/1/2006 N21390 1/1/2006 N21395 1/1/2006 N21400 7/1/2004 N21401 7/1/2004 N21406 7/1/2004 N21407 7/1/2004 N21408 1/1/2006 N21421 7/1/2004 N21440 7/1/2004 N21445 7/1/2004 N21450 7/1/2004 N21451 7/1/2004 N21452 7/1/2004 N21453 7/1/2004 N

Page 9 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range21454 7/1/2004 N21461 7/1/2004 N21462 7/1/2004 N21465 7/1/2004 N21470 1/1/2006 N21480 7/1/2004 N21485 7/1/2004 N21490 7/1/2004 N21497 7/1/2004 N21499 7/1/2004 N21501 7/1/2004 N21502 7/1/2004 N21550 7/1/2004 N21552 1/1/2010 N21554 1/1/2010 N21555 7/1/2004 N21556 7/1/2004 N21557 1/1/2006 N21558 1/1/2010 N21600 7/1/2004 N21610 1/1/2006 N21685 1/1/2006 N21700 7/1/2004 N21720 7/1/2004 N21725 7/1/2004 N21742 1/1/2006 N21743 1/1/2006 N21800 7/1/2004 N21820 7/1/2004 N21899 7/1/2004 N21920 7/1/2004 N21925 7/1/2004 N21930 7/1/2004 N21931 1/1/2010 N21932 1/1/2010 N21933 1/1/2010 N21935 1/1/2010 N21936 1/1/2010 N22100 7/1/2004 N22101 7/1/2004 N22102 7/1/2004 N22103 7/1/2004 N22222 7/1/2004 N22310 7/1/2004 N22315 7/1/2004 N22505 7/1/2004 N22510 1/1/2015 N22511 1/1/2015 N22512 1/1/2015 N22513 1/1/2015 N22514 1/1/2015 N22515 1/1/2015 N22551 1/1/2011 N22554 7/1/2004 N

Page 10 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range22612 7/1/2004 N22614 1/1/2006 N22853 1/1/2017 N22854 1/1/2017 N22856 1/1/2009 N22858 1/1/2015 N22859 1/1/2017 N22867 1/1/2017 N22868 1/1/2017 N22869 1/1/2017 N22870 1/1/2017 N22899 7/1/2004 N22900 7/1/2004 N22901 1/1/2010 N22902 1/1/2010 N22903 1/1/2010 N22904 1/1/2010 N22905 1/1/2010 N22999 7/1/2004 N23000 7/1/2004 N23020 7/1/2004 N23030 7/1/2004 N23031 7/1/2004 N23035 7/1/2004 N23040 7/1/2004 N23044 7/1/2004 N23065 7/1/2004 N23066 7/1/2004 N23071 1/1/2010 N23073 1/1/2010 N23075 7/1/2004 N23076 7/1/2004 N23077 1/1/2006 N23078 1/1/2010 N23100 7/1/2004 N23101 7/1/2004 N23105 7/1/2004 N23106 7/1/2004 N23107 7/1/2004 N23120 7/1/2004 N23125 1/1/2006 N23130 7/1/2004 N23140 7/1/2004 N23145 7/1/2004 N23146 7/1/2004 N23150 7/1/2004 N23155 7/1/2004 N23156 7/1/2004 N23170 7/1/2004 N23172 7/1/2004 N23174 7/1/2004 N23180 7/1/2004 N23182 7/1/2004 N23184 7/1/2004 N

Page 11 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range23190 7/1/2004 N23195 7/1/2004 N23330 7/1/2004 N23333 1/1/2014 N23334 1/1/2014 N23350 7/1/2004 N23395 7/1/2004 N23397 7/1/2004 N23400 7/1/2004 N23405 7/1/2004 N23406 7/1/2004 N23410 7/1/2004 N23412 7/1/2004 N23415 7/1/2004 N23420 7/1/2004 N23430 7/1/2004 N23440 7/1/2004 N23450 7/1/2004 N23455 7/1/2004 N23460 7/1/2004 N23462 7/1/2004 N23465 7/1/2004 N23466 7/1/2004 N23470 7/1/2004 N23473 1/1/2013 N23480 7/1/2004 N23485 7/1/2004 N23490 7/1/2004 N23491 7/1/2004 N23500 1/1/2006 N23505 7/1/2004 N23515 7/1/2004 N23520 7/1/2004 N23525 7/1/2004 N23530 7/1/2004 N23532 7/1/2004 N23540 7/1/2004 N23545 7/1/2004 N23550 7/1/2004 N23552 7/1/2004 N23570 7/1/2004 N23575 7/1/2004 N23585 7/1/2004 N23600 1/1/2006 N23605 7/1/2004 N23615 7/1/2004 N23616 7/1/2004 N23620 7/1/2004 N23625 7/1/2004 N23630 7/1/2004 N23650 7/1/2004 N23655 7/1/2004 N23660 7/1/2004 N23665 7/1/2004 N

Page 12 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range23670 7/1/2004 N23675 7/1/2004 N23680 7/1/2004 N23700 7/1/2004 N23800 7/1/2004 N23802 7/1/2004 N23921 7/1/2004 N23929 7/1/2004 N23930 7/1/2004 N23931 7/1/2004 N23935 7/1/2004 N24000 7/1/2004 N24006 7/1/2004 N24065 7/1/2004 N24066 7/1/2004 N24071 1/1/2010 N24073 1/1/2010 N24075 7/1/2004 N24076 1/1/2010 N24077 1/1/2006 N24079 1/1/2010 N24100 7/1/2004 N24101 7/1/2004 N24102 7/1/2004 N24105 7/1/2004 N24110 7/1/2004 N24115 7/1/2004 N24116 7/1/2004 N24120 7/1/2004 N24125 7/1/2004 N24126 7/1/2004 N24130 7/1/2004 N24134 7/1/2004 N24136 7/1/2004 N24138 7/1/2004 N24140 7/1/2004 N24145 7/1/2004 N24147 7/1/2004 N24149 7/1/2004 N24150 1/1/2006 N24152 1/1/2006 N24155 1/1/2006 N24160 7/1/2004 N24164 7/1/2004 N24200 7/1/2004 N24201 7/1/2004 N24220 7/1/2004 N24300 7/1/2004 N24301 7/1/2004 N24305 7/1/2004 N24310 7/1/2004 N24320 7/1/2004 N24330 7/1/2004 N24331 7/1/2004 N

Page 13 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range24332 7/1/2004 N24340 7/1/2004 N24341 7/1/2005 N24342 7/1/2004 N24343 7/1/2004 N24344 7/1/2004 N24345 7/1/2004 N24346 7/1/2004 N24357 1/1/2008 N24358 1/1/2008 N24359 1/1/2008 N24360 7/1/2004 N24361 7/1/2004 N24362 7/1/2004 N24363 1/1/2006 N24365 7/1/2004 N24366 7/1/2004 N24370 1/1/2013 N24371 1/1/2013 N24400 7/1/2004 N24410 1/1/2006 N24420 7/1/2004 N24430 7/1/2004 N24435 7/1/2004 N24470 7/1/2004 N24495 7/1/2004 N24498 7/1/2004 N24500 7/1/2004 N24505 7/1/2004 N24515 7/1/2004 N24516 7/1/2004 N24530 7/1/2004 N24535 7/1/2004 N24538 7/1/2004 N24545 7/1/2004 N24546 7/1/2004 N24560 7/1/2004 N24565 7/1/2004 N24566 7/1/2004 N24575 7/1/2004 N24576 7/1/2004 N24577 7/1/2004 N24579 7/1/2004 N24582 7/1/2004 N24586 7/1/2004 N24587 7/1/2004 N24600 1/1/2006 N24605 7/1/2004 N24615 7/1/2004 N24620 7/1/2004 N24635 7/1/2004 N24640 7/1/2004 N24650 1/1/2006 N24655 7/1/2004 N

Page 14 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range24665 7/1/2004 N24666 7/1/2004 N24670 7/1/2004 N24675 7/1/2004 N24685 7/1/2004 N24800 7/1/2004 N24802 7/1/2004 N24925 7/1/2004 N24935 1/1/2006 N24999 7/1/2004 N25000 7/1/2004 N25001 7/1/2004 N25020 7/1/2004 N25023 7/1/2004 N25024 7/1/2004 N25025 7/1/2004 N25028 7/1/2004 N25031 7/1/2004 N25035 7/1/2004 N25040 7/1/2004 N25065 7/1/2004 N25066 7/1/2004 N25071 1/1/2010 N25073 1/1/2010 N25075 7/1/2004 N25076 7/1/2004 N25077 1/1/2010 N25078 1/1/2010 N25085 7/1/2004 N25100 7/1/2004 N25101 7/1/2004 N25105 7/1/2004 N25107 7/1/2004 N25109 1/1/2007 N25110 7/1/2004 N25111 7/1/2004 N25112 7/1/2004 N25115 7/1/2004 N25116 7/1/2004 N25118 7/1/2004 N25119 7/1/2004 N25120 7/1/2004 N25125 7/1/2004 N25126 7/1/2004 N25130 7/1/2004 N25135 7/1/2004 N25136 7/1/2004 N25145 7/1/2004 N25150 7/1/2004 N25151 7/1/2004 N25170 7/1/2004 N25210 7/1/2004 N25215 7/1/2004 N25230 7/1/2004 N

Page 15 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range25240 7/1/2004 N25246 7/1/2004 N25248 7/1/2004 N25250 7/1/2004 N25251 7/1/2004 N25259 7/1/2004 N25260 7/1/2004 N25263 7/1/2004 N25265 7/1/2004 N25270 7/1/2004 N25272 7/1/2004 N25274 7/1/2004 N25275 7/1/2004 N25280 7/1/2004 N25290 7/1/2004 N25295 7/1/2004 N25300 7/1/2004 N25301 7/1/2004 N25310 7/1/2004 N25312 7/1/2004 N25315 7/1/2004 N25316 7/1/2004 N25320 7/1/2004 N25332 7/1/2004 N25335 7/1/2004 N25337 7/1/2004 N25350 7/1/2004 N25355 7/1/2004 N25360 7/1/2004 N25365 7/1/2004 N25370 7/1/2004 N25375 7/1/2004 N25390 7/1/2004 N25391 7/1/2004 N25392 7/1/2004 N25393 7/1/2004 N25394 7/1/2004 N25400 7/1/2004 N25405 7/1/2004 N25415 7/1/2004 N25420 7/1/2004 N25425 7/1/2004 N25426 7/1/2004 N25430 7/1/2004 N25431 7/1/2004 N25440 7/1/2004 N25441 7/1/2004 N25442 7/1/2004 N25443 7/1/2004 N25444 7/1/2004 N25445 7/1/2004 N25446 7/1/2004 N25447 7/1/2004 N25449 7/1/2004 N

Page 16 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range25450 7/1/2004 N25455 7/1/2004 N25490 7/1/2004 N25491 7/1/2004 N25492 7/1/2004 N25500 1/1/2006 N25505 7/1/2004 N25515 7/1/2004 N25520 7/1/2004 N25525 7/1/2004 N25526 7/1/2004 N25530 1/1/2006 N25535 7/1/2004 N25545 7/1/2004 N25560 7/1/2004 N25565 7/1/2004 N25574 7/1/2004 N25575 7/1/2004 N25600 1/1/2006 N25605 7/1/2004 N25606 1/1/2007 N25607 1/1/2007 N25608 1/1/2007 N25609 1/1/2007 N25622 7/1/2004 N25624 7/1/2004 N25628 7/1/2004 N25630 1/1/2006 N25635 7/1/2004 N25645 7/1/2004 N25650 7/1/2004 N25651 7/1/2004 N25652 7/1/2004 N25660 7/1/2004 N25670 7/1/2004 N25671 7/1/2004 N25675 7/1/2004 N25676 7/1/2004 N25680 7/1/2004 N25685 7/1/2004 N25690 7/1/2004 N25695 7/1/2004 N25800 7/1/2004 N25805 7/1/2004 N25810 7/1/2004 N25820 7/1/2004 N25825 7/1/2004 N25830 7/1/2004 N25907 7/1/2004 N25909 1/1/2006 N25922 7/1/2004 N25929 7/1/2004 N25931 7/1/2004 N25999 7/1/2004 N

Page 17 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range26010 7/1/2004 N26011 7/1/2004 N26020 7/1/2004 N26025 7/1/2004 N26030 7/1/2004 N26034 7/1/2004 N26035 7/1/2004 N26037 7/1/2004 N26040 7/1/2004 N26045 7/1/2004 N26055 7/1/2004 N26060 7/1/2004 N26070 7/1/2004 N26075 7/1/2004 N26080 7/1/2004 N26100 7/1/2004 N26105 7/1/2004 N26110 7/1/2004 N26111 1/1/2010 N26113 1/1/2010 N26115 7/1/2004 N26116 7/1/2004 N26117 7/1/2004 N26118 1/1/2010 N26121 7/1/2004 N26123 7/1/2004 N26125 1/1/2006 N26130 7/1/2004 N26135 7/1/2004 N26140 7/1/2004 N26145 7/1/2004 N26160 7/1/2004 N26170 7/1/2004 N26180 7/1/2004 N26185 7/1/2004 N26200 7/1/2004 N26205 7/1/2004 N26210 7/1/2004 N26215 7/1/2004 N26230 7/1/2004 N26235 7/1/2004 N26236 7/1/2004 N26250 7/1/2004 N26260 7/1/2004 N26262 7/1/2004 N26320 7/1/2004 N26340 1/1/2006 N26350 7/1/2004 N26352 7/1/2004 N26356 7/1/2004 N26357 7/1/2004 N26358 7/1/2004 N26370 7/1/2004 N26372 7/1/2004 N

Page 18 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range26373 7/1/2004 N26390 7/1/2004 N26392 7/1/2004 N26410 7/1/2004 N26412 7/1/2004 N26415 7/1/2004 N26416 7/1/2004 N26418 7/1/2004 N26420 7/1/2004 N26426 7/1/2004 N26428 7/1/2004 N26432 7/1/2004 N26433 7/1/2004 N26434 7/1/2004 N26437 7/1/2004 N26440 7/1/2004 N26442 7/1/2004 N26445 7/1/2004 N26449 7/1/2004 N26450 7/1/2004 N26455 7/1/2004 N26460 7/1/2004 N26471 7/1/2004 N26474 7/1/2004 N26476 7/1/2004 N26477 7/1/2004 N26478 7/1/2004 N26479 7/1/2004 N26480 7/1/2004 N26483 7/1/2004 N26485 7/1/2004 N26489 7/1/2004 N26490 7/1/2004 N26492 7/1/2004 N26494 7/1/2004 N26496 7/1/2004 N26497 7/1/2004 N26498 7/1/2004 N26499 7/1/2004 N26500 7/1/2004 N26502 7/1/2004 N26508 7/1/2004 N26510 7/1/2004 N26516 7/1/2004 N26517 7/1/2004 N26518 7/1/2004 N26520 7/1/2004 N26525 7/1/2004 N26530 7/1/2004 N26531 7/1/2004 N26535 7/1/2004 N26536 7/1/2004 N26540 7/1/2004 N26541 7/1/2004 N

Page 19 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range26542 7/1/2004 N26545 7/1/2004 N26546 7/1/2004 N26548 7/1/2004 N26550 7/1/2004 N26555 7/1/2004 N26560 7/1/2004 N26561 7/1/2004 N26562 7/1/2004 N26565 7/1/2004 N26567 7/1/2004 N26568 7/1/2004 N26580 7/1/2004 N26587 7/1/2004 N26590 7/1/2004 N26591 7/1/2004 N26593 7/1/2004 N26596 7/1/2004 N26600 1/1/2006 N26605 7/1/2004 N26607 7/1/2004 N26608 7/1/2004 N26615 7/1/2004 N26641 1/1/2006 N26645 7/1/2004 N26650 7/1/2004 N26665 7/1/2004 N26670 7/1/2004 N26675 7/1/2004 N26676 7/1/2004 N26685 7/1/2004 N26686 7/1/2004 N26700 1/1/2006 N26705 7/1/2004 N26706 7/1/2004 N26715 7/1/2004 N26720 1/1/2006 N26725 7/1/2004 N26727 7/1/2004 N26735 7/1/2004 N26740 1/1/2006 N26742 7/1/2004 N26746 7/1/2004 N26750 1/1/2006 N26755 7/1/2004 N26756 7/1/2004 N26765 7/1/2004 N26770 1/1/2006 N26775 7/1/2004 N26776 7/1/2004 N26785 7/1/2004 N26820 7/1/2004 N26841 7/1/2004 N26842 7/1/2004 N

Page 20 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range26843 7/1/2004 N26844 7/1/2004 N26850 7/1/2004 N26852 7/1/2004 N26860 7/1/2004 N26861 1/1/2006 N26862 7/1/2004 N26863 1/1/2006 N26910 7/1/2004 N26951 7/1/2004 N26952 7/1/2004 N26989 7/1/2004 N26990 7/1/2004 N26991 7/1/2004 N27000 7/1/2004 N27001 7/1/2004 N27003 7/1/2004 N27006 7/1/2004 N27027 1/1/2009 N27033 7/1/2004 N27035 7/1/2004 N27040 1/1/2006 N27041 7/1/2004 N27043 1/1/2010 N27045 1/1/2010 N27047 7/1/2004 N27048 1/1/2010 N27049 1/1/2006 N27050 7/1/2004 N27052 7/1/2004 N27057 1/1/2009 N27059 1/1/2010 N27060 7/1/2004 N27062 7/1/2004 N27065 7/1/2004 N27066 7/1/2004 N27067 7/1/2004 N27080 7/1/2004 N27086 7/1/2004 N27087 7/1/2004 N27093 7/1/2004 N27095 7/1/2004 N27096 7/1/2004 N27097 7/1/2004 N27098 7/1/2004 N27100 7/1/2004 N27105 7/1/2004 N27110 7/1/2004 N27111 7/1/2004 N27179 1/1/2006 N27197 1/1/2017 N27198 1/1/2017 N27200 7/1/2004 N27202 7/1/2004 N

Page 21 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range27215 7/1/2004 N27216 7/1/2004 N27217 7/1/2004 N27218 7/1/2004 N27220 7/1/2004 N27230 7/1/2004 N27235 1/1/2006 N27238 7/1/2004 N27246 7/1/2004 N27250 7/1/2004 N27252 7/1/2004 N27256 7/1/2004 N27257 7/1/2004 N27265 7/1/2004 N27266 7/1/2004 N27267 1/1/2008 N27275 7/1/2004 N27299 7/1/2004 N27301 7/1/2004 N27305 7/1/2004 N27306 7/1/2004 N27307 7/1/2004 N27310 7/1/2004 N27323 7/1/2004 N27324 7/1/2004 N27325 1/1/2007 N27326 1/1/2007 N27327 7/1/2004 N31595 7/1/2004 N27329 1/1/2006 N27330 7/1/2004 N27331 7/1/2004 N27332 7/1/2004 N27333 7/1/2004 N27334 7/1/2004 N27335 7/1/2004 N27337 1/1/2010 N27339 1/1/2010 N27340 7/1/2004 N27345 7/1/2004 N27347 7/1/2004 N27350 7/1/2004 N27355 7/1/2004 N27356 7/1/2004 N27357 7/1/2004 N27358 1/1/2006 N27360 7/1/2004 N27364 1/1/2010 N27369 1/1/2019 N27372 7/1/2004 N27380 7/1/2004 N27381 7/1/2004 N27385 7/1/2004 N27386 7/1/2004 N

Page 22 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range27390 7/1/2004 N27391 7/1/2004 N27392 7/1/2004 N27393 7/1/2004 N27394 7/1/2004 N27395 7/1/2004 N27396 7/1/2004 N27397 7/1/2004 N27400 7/1/2004 N27403 7/1/2004 N27405 7/1/2004 N27407 7/1/2004 N27409 7/1/2004 N27412 1/1/2005 N27415 1/1/2005 N27416 1/1/2008 N27418 7/1/2004 N27420 7/1/2004 N27422 7/1/2004 N27424 1/1/2006 N27425 7/1/2004 N27427 7/1/2004 N27428 7/1/2004 N27429 7/1/2004 N27430 1/1/2006 N27435 7/1/2004 N27437 7/1/2004 N27438 7/1/2004 N27440 7/1/2004 N27441 7/1/2004 N27442 7/1/2004 N27443 7/1/2004 N27446 7/1/2004 N27475 7/1/2004 N27479 7/1/2004 N27496 7/1/2004 N27497 7/1/2004 N27498 7/1/2004 N27499 7/1/2004 N27500 7/1/2004 N27501 1/1/2006 N27502 7/1/2004 N27503 1/1/2006 N27508 7/1/2004 N27509 7/1/2004 N27510 7/1/2004 N27516 7/1/2004 N27517 7/1/2004 N27520 7/1/2004 N27524 7/1/2004 N27530 7/1/2004 N27532 7/1/2004 N27538 7/1/2004 N27550 7/1/2004 N

Page 23 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range27552 7/1/2004 N27560 7/1/2004 N27562 7/1/2004 N27566 7/1/2004 N27570 7/1/2004 N27594 7/1/2004 N27599 1/1/2006 N27600 7/1/2004 N27601 7/1/2004 N27602 7/1/2004 N27603 7/1/2004 N27604 7/1/2004 N27605 7/1/2004 N27606 7/1/2004 N27607 7/1/2004 N27610 7/1/2004 N27612 7/1/2004 N27613 7/1/2004 N27614 7/1/2004 N27615 1/1/2010 N27616 1/1/2010 N27618 7/1/2004 N27619 7/1/2004 N27620 7/1/2004 N27625 7/1/2004 N27626 7/1/2004 N27630 7/1/2004 N27632 1/1/2010 N27634 1/1/2010 N27635 7/1/2004 N27637 7/1/2004 N27638 7/1/2004 N27640 7/1/2004 N27641 7/1/2004 N27647 1/1/2010 N27648 7/1/2004 N27650 7/1/2004 N27652 7/1/2004 N27654 7/1/2004 N27656 7/1/2004 N27658 7/1/2004 N27659 7/1/2004 N27664 7/1/2004 N27665 7/1/2004 N27675 7/1/2004 N27676 7/1/2004 N27680 7/1/2004 N27681 7/1/2004 N27685 7/1/2004 N27686 7/1/2004 N27687 7/1/2004 N27690 7/1/2004 N27691 7/1/2004 N27692 1/1/2006 N

Page 24 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range27695 7/1/2004 N27696 7/1/2004 N27698 7/1/2004 N27700 7/1/2004 N27704 7/1/2004 N27705 7/1/2004 N27707 7/1/2004 N27709 7/1/2004 N27720 7/1/2004 N27722 7/1/2004 N27726 1/1/2008 N27730 7/1/2004 N27732 7/1/2004 N27734 7/1/2004 N27740 7/1/2004 N27742 7/1/2004 N27745 7/1/2004 N27750 7/1/2004 N27752 7/1/2004 N27756 7/1/2004 N27758 7/1/2004 N27759 7/1/2004 N27760 1/1/2006 N27762 7/1/2004 N27766 7/1/2004 N27767 1/1/2008 N27768 1/1/2008 N27769 1/1/2008 N27780 1/1/2006 N27781 7/1/2004 N27784 7/1/2004 N27786 1/1/2006 N27788 7/1/2004 N27792 7/1/2004 N27808 7/1/2004 N27810 7/1/2004 N27814 7/1/2004 N27816 7/1/2004 N27818 7/1/2004 N27822 7/1/2004 N27823 7/1/2004 N27824 7/1/2004 N27825 7/1/2004 N27826 7/1/2004 N27827 7/1/2004 N27828 7/1/2004 N27829 7/1/2004 N27830 7/1/2004 N27831 7/1/2004 N27832 7/1/2004 N27840 7/1/2004 N27842 7/1/2004 N27846 7/1/2004 N27848 7/1/2004 N

Page 25 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range27860 7/1/2004 N27870 7/1/2004 N27871 7/1/2004 N27884 7/1/2004 N27889 1/1/2006 N27892 7/1/2004 N27893 7/1/2004 N27894 7/1/2004 N28001 7/1/2004 N28002 7/1/2004 N28003 7/1/2004 N28005 7/1/2004 N28008 7/1/2004 N28010 7/1/2004 N28011 7/1/2004 N28020 7/1/2004 N28022 7/1/2004 N28024 7/1/2004 N28035 7/1/2004 N28039 1/1/2010 N28041 1/1/2010 N28043 7/1/2004 N28045 7/1/2004 N28046 1/1/2006 N28047 1/1/2010 N28050 7/1/2004 N28052 7/1/2004 N28054 7/1/2004 N28055 1/1/2007 N28060 7/1/2004 N28062 7/1/2004 N28070 7/1/2004 N28072 7/1/2004 N28080 7/1/2004 N28086 7/1/2004 N28088 7/1/2004 N28090 7/1/2004 N28092 7/1/2004 N28100 7/1/2004 N28102 7/1/2004 N28103 7/1/2004 N28104 7/1/2004 N28106 7/1/2004 N28107 7/1/2004 N28108 7/1/2004 N28110 7/1/2004 N28111 7/1/2004 N28112 7/1/2004 N28113 7/1/2004 N28114 7/1/2004 N28116 7/1/2004 N28118 7/1/2004 N28119 7/1/2004 N28120 7/1/2004 N

Page 26 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range28122 7/1/2004 N28124 7/1/2004 N28126 7/1/2004 N28130 7/1/2004 N28140 7/1/2004 N28150 7/1/2004 N28153 7/1/2004 N28160 7/1/2004 N28171 7/1/2004 N28173 7/1/2004 N28175 7/1/2004 N28190 7/1/2004 N28192 7/1/2004 N28193 7/1/2004 N28200 7/1/2004 N28202 7/1/2004 N28208 7/1/2004 N28210 7/1/2004 N28220 7/1/2004 N28222 7/1/2004 N28225 7/1/2004 N28226 7/1/2004 N28230 7/1/2004 N28232 7/1/2004 N28234 7/1/2004 N28238 7/1/2004 N28240 7/1/2004 N28250 7/1/2004 N28260 7/1/2004 N28261 7/1/2004 N28262 7/1/2004 N28264 7/1/2004 N28270 7/1/2004 N28272 7/1/2004 N28280 7/1/2004 N28285 7/1/2004 N28286 7/1/2004 N28288 7/1/2004 N28289 7/1/2004 N28291 1/1/2017 N28292 7/1/2004 N28295 1/1/2017 N28296 7/1/2004 N28297 7/1/2004 N28298 7/1/2004 N28299 7/1/2004 N28300 7/1/2004 N28302 7/1/2004 N28304 7/1/2004 N28305 7/1/2004 N28306 7/1/2004 N28307 7/1/2004 N28308 7/1/2004 N28309 7/1/2004 N

Page 27 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range28310 7/1/2004 N28312 7/1/2004 N28313 7/1/2004 N28315 7/1/2004 N28320 7/1/2004 N28322 7/1/2004 N28340 7/1/2004 N28341 7/1/2004 N28344 7/1/2004 N28345 7/1/2004 N28360 7/1/2004 N28400 7/1/2004 N28405 7/1/2004 N28406 7/1/2004 N28415 7/1/2004 N28420 7/1/2004 N28430 7/1/2004 N28435 7/1/2004 N28436 7/1/2004 N28445 7/1/2004 N28446 1/1/2008 N28450 7/1/2004 N28455 7/1/2004 N28456 7/1/2004 N28465 7/1/2004 N28470 7/1/2004 N28475 7/1/2004 N28476 7/1/2004 N28485 7/1/2004 N28490 1/1/2006 N28495 7/1/2004 N28496 7/1/2004 N28505 7/1/2004 N28510 1/1/2006 N28515 7/1/2004 N28525 7/1/2004 N28530 1/1/2006 N28531 7/1/2004 N28540 7/1/2004 N28545 7/1/2004 N28546 7/1/2004 N28555 7/1/2004 N28570 7/1/2004 N28575 7/1/2004 N28576 7/1/2004 N28585 7/1/2004 N28600 7/1/2004 N28605 7/1/2004 N28606 7/1/2004 N28615 7/1/2004 N28630 7/1/2004 N28635 7/1/2004 N28636 7/1/2004 N28645 7/1/2004 N

Page 28 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range28660 1/1/2006 N28665 7/1/2004 N28666 7/1/2004 N28675 7/1/2004 N28705 7/1/2004 N28715 7/1/2004 N28725 7/1/2004 N28730 7/1/2004 N28735 7/1/2004 N28737 7/1/2004 N28740 7/1/2004 N28750 7/1/2004 N28755 7/1/2004 N28760 7/1/2004 N28805 1/1/2006 N28810 1/1/2006 N28820 7/1/2004 N28825 7/1/2004 N28890 1/1/2006 N28899 7/1/2004 N29800 7/1/2004 N29804 7/1/2004 N29805 7/1/2004 N29806 7/1/2004 N29807 7/1/2004 N29819 7/1/2004 N29820 7/1/2004 N29821 7/1/2004 N29822 7/1/2004 N29823 7/1/2004 N29824 7/1/2004 N29825 7/1/2004 N29826 7/1/2004 N29827 7/1/2004 N29828 1/1/2008 N29830 7/1/2004 N29834 7/1/2004 N29835 7/1/2004 N29836 7/1/2004 N29837 7/1/2004 N29838 7/1/2004 N29840 7/1/2004 N29843 7/1/2004 N29844 7/1/2004 N29845 7/1/2004 N29846 7/1/2004 N29847 7/1/2004 N29848 7/1/2004 N29850 7/1/2004 N29851 7/1/2004 N29855 7/1/2004 N29856 7/1/2004 N29860 7/1/2004 N29861 7/1/2004 N

Page 29 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range29862 7/1/2004 N29863 7/1/2004 N29866 1/1/2005 N29867 1/1/2005 N29868 1/1/2005 N29870 7/1/2004 N29871 7/1/2004 N29873 7/1/2004 N29874 7/1/2004 N29875 7/1/2004 N29876 7/1/2004 N29877 7/1/2004 N29879 7/1/2004 N29880 7/1/2004 N29881 7/1/2004 N29882 7/1/2004 N29883 7/1/2004 N29884 7/1/2004 N29885 7/1/2004 N29886 7/1/2004 N29887 7/1/2004 N29888 7/1/2004 N29889 7/1/2004 N29891 7/1/2004 N29892 7/1/2004 N29893 7/1/2004 N29894 7/1/2004 N29895 7/1/2004 N29897 7/1/2004 N29898 7/1/2004 N29899 7/1/2004 N29900 7/1/2004 N29901 7/1/2004 N29902 7/1/2004 N29904 1/1/2008 N29905 1/1/2008 N29906 1/1/2008 N29907 1/1/2008 N29914 1/1/2011 N29915 1/1/2011 N29916 1/1/2011 N29999 7/1/2004 N30000 7/1/2004 N30020 7/1/2004 N30100 7/1/2004 N30110 7/1/2004 N30115 7/1/2004 N30117 7/1/2004 N30118 7/1/2004 N30120 7/1/2004 N30124 1/1/2006 N30125 7/1/2004 N30130 7/1/2004 N30140 7/1/2004 N

Page 30 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range30150 7/1/2004 N30160 1/1/2006 N30200 1/1/2006 N30210 7/1/2004 N30220 7/1/2004 N30310 7/1/2004 N30320 7/1/2004 N30400 7/1/2004 N30410 7/1/2004 N30420 7/1/2004 N30430 1/1/2006 N30435 7/1/2004 N30450 7/1/2004 N30460 7/1/2004 N30462 7/1/2004 N30465 7/1/2004 N30520 7/1/2004 N30540 7/1/2004 N30545 7/1/2004 N30560 7/1/2004 N30580 7/1/2004 N30600 7/1/2004 N30620 7/1/2004 N30630 7/1/2004 N30801 7/1/2004 N30802 7/1/2004 N30901 7/1/2004 N30903 7/1/2004 N30905 7/1/2004 N30906 7/1/2004 N30915 7/1/2004 N30920 7/1/2004 N30930 7/1/2004 N30999 7/1/2004 N31000 7/1/2004 N31002 7/1/2004 N31020 7/1/2004 N31030 7/1/2004 N31032 7/1/2004 N31040 7/1/2004 N31050 7/1/2004 N31051 7/1/2004 N31070 7/1/2004 N31075 7/1/2004 N31080 7/1/2004 N31081 7/1/2004 N31084 1/1/2006 N31085 7/1/2004 N31086 7/1/2004 N31087 7/1/2004 N31090 7/1/2004 N31200 7/1/2004 N31201 7/1/2004 N31205 7/1/2004 N

Page 31 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range31231 1/1/2006 N31233 7/1/2004 N31235 7/1/2004 N31237 7/1/2004 N31238 7/1/2004 N31239 7/1/2004 N31240 7/1/2004 N31241 1/1/2018 N31253 1/1/2018 N31254 7/1/2004 N31255 7/1/2004 N31256 7/1/2004 N31257 1/1/2018 N31259 1/1/2018 N31267 7/1/2004 N31276 7/1/2004 N31287 7/1/2004 N31288 7/1/2004 N31292 7/1/2004 N31293 7/1/2004 N31294 7/1/2004 N31295 1/1/2011 N31296 1/1/2011 N31297 1/1/2011 N31298 1/1/2018 N31299 7/1/2004 N31300 7/1/2004 N31400 7/1/2004 N31420 1/1/2006 N31505 7/1/2004 N31510 7/1/2004 N31511 7/1/2004 N31512 7/1/2004 N31513 7/1/2004 N31515 7/1/2004 N31520 7/1/2004 Y 0 through 4 weeks31525 7/1/2004 N31526 7/1/2004 N31527 7/1/2004 N31528 7/1/2004 N31529 7/1/2004 N31530 7/1/2004 N31531 7/1/2004 N31535 7/1/2004 N31536 7/1/2004 N31540 7/1/2004 N31541 7/1/2004 N31545 1/1/2005 N31546 1/1/2005 N31551 1/1/2017 Y 0 through 11 years31552 1/1/2017 Y 12 through 99 years31553 1/1/2017 Y 0 through 11 years31554 1/1/2017 Y 12 through 99 years31560 7/1/2004 N

Page 32 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range31561 7/1/2004 N31570 7/1/2004 N31571 7/1/2004 N31572 1/1/2017 N31573 1/1/2017 N31574 1/1/2017 N31575 7/1/2004 N31576 7/1/2004 N31577 7/1/2004 N31578 7/1/2004 N31579 7/1/2004 N31580 7/1/2004 N31590 7/1/2004 N31591 1/1/2017 N31592 1/1/2017 N31599 7/1/2004 N31600 7/1/2004 N31601 7/1/2004 Y 0 through 2 years31603 7/1/2004 N31605 7/1/2004 N31610 7/1/2004 N31611 7/1/2004 N31612 7/1/2004 N31613 7/1/2004 N31614 7/1/2004 N31615 7/1/2004 N31622 7/1/2004 N31623 7/1/2004 N31624 7/1/2004 N31625 7/1/2004 N31626 1/1/2010 N31627 1/1/2010 N31628 7/1/2004 N31629 7/1/2004 N31630 7/1/2004 N31631 7/1/2004 N31632 7/1/2004 N31633 7/1/2004 N31634 1/1/2011 N31635 7/1/2004 N31636 1/1/2005 N31637 1/1/2006 N31638 1/1/2005 N31640 7/1/2004 N31641 7/1/2004 N31643 7/1/2004 N31645 7/1/2004 N31646 7/1/2004 N31647 1/1/2013 N31648 1/1/2013 N31649 1/1/2013 N31651 1/1/2013 N31652 1/1/2016 N31653 1/1/2016 N

Page 33 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range31654 1/1/2016 N31660 1/1/2013 N31661 1/1/2013 N31717 7/1/2004 N31730 7/1/2004 N31750 7/1/2004 N31755 7/1/2004 N31785 1/1/2006 N31820 7/1/2004 N31825 7/1/2004 N31830 7/1/2004 N32400 7/1/2004 N32405 7/1/2004 N32550 1/1/2008 N32551 1/1/2008 N32553 1/1/2010 N32554 1/1/2013 N32555 1/1/2013 N32556 1/1/2013 N32557 1/1/2013 N32560 1/1/2008 N32540 1/1/2006 N32601 7/1/2004 N32604 7/1/2004 N32606 7/1/2004 N32607 1/1/2012 N32608 1/1/2012 N32609 1/1/2012 N32960 1/1/2006 N32994 1/1/2018 N32998 1/1/2007 N33010 1/1/2006 N33011 1/1/2006 N33206 7/1/2004 N33207 7/1/2004 N33208 7/1/2004 N33210 7/1/2004 N33211 7/1/2004 N33212 7/1/2004 N33213 7/1/2004 N33214 7/1/2004 N33215 7/1/2004 N33216 7/1/2004 N33217 7/1/2004 N33218 7/1/2004 N33220 7/1/2004 N33221 1/1/2012 N33222 7/1/2004 N33223 7/1/2004 N33224 7/1/2004 N33225 1/1/2006 N33226 7/1/2004 N33227 1/1/2012 N33228 1/1/2012 N

Page 34 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range33229 1/1/2012 N33230 1/1/2012 N33231 1/1/2012 N33233 7/1/2004 N33234 7/1/2004 N33235 7/1/2004 N33240 7/1/2004 N33241 7/1/2004 N33244 7/1/2004 N33249 7/1/2004 N33262 1/1/2012 N33263 1/1/2012 N33264 1/1/2012 N33270 1/1/2015 N33271 1/1/2015 N33272 1/1/2015 N33273 1/1/2015 N33274 1/1/2019 N33275 1/1/2019 N33285 1/1/2019 N33286 1/1/2019 N33289 1/1/2019 N33340 1/1/2017 N34101 7/1/2004 N34111 7/1/2004 N34201 7/1/2004 N34203 7/1/2004 N34421 7/1/2004 N34471 7/1/2004 N34490 7/1/2004 N34501 7/1/2004 N34510 1/1/2006 N34520 1/1/2006 N34530 7/1/2004 N35011 1/1/2006 N35045 1/1/2006 N35180 1/1/2006 N35184 7/1/2004 N35188 1/1/2006 N35190 7/1/2004 N35201 7/1/2004 N35206 7/1/2004 N35207 7/1/2004 N35226 7/1/2004 N35231 1/1/2006 N35236 7/1/2004 N35256 7/1/2004 N35261 1/1/2006 N35266 7/1/2004 N35286 7/1/2004 N35321 1/1/2006 N35500 1/1/2006 N35572 1/1/2006 N35761 7/1/2004 N

Page 35 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range35860 7/1/2004 N35875 7/1/2004 N35876 7/1/2004 N35879 7/1/2004 N35881 7/1/2004 N35883 1/1/2007 N35884 1/1/2007 N35903 7/1/2004 N36002 7/1/2004 N36005 7/1/2004 N36010 7/1/2004 N36011 7/1/2004 N36012 7/1/2004 N36013 7/1/2004 N36014 7/1/2004 N36015 7/1/2004 N36100 7/1/2004 N36140 7/1/2004 N36160 7/1/2004 N36200 7/1/2004 N36215 7/1/2004 N36216 7/1/2004 N36217 7/1/2004 N36218 1/1/2006 N36221 1/1/2013 N36222 1/1/2013 N36223 1/1/2013 N36224 1/1/2013 N36225 1/1/2013 N36226 1/1/2013 N36227 1/1/2013 N36228 1/1/2013 N36245 7/1/2004 N36246 7/1/2004 N36247 7/1/2004 N36248 1/1/2006 N36251 1/1/2012 N36252 1/1/2012 N36253 1/1/2012 N36254 1/1/2012 N36260 7/1/2004 N36261 7/1/2004 N36262 7/1/2004 N36299 7/1/2004 N36400 7/1/2004 Y 0 through 2 years36405 7/1/2004 Y 0 through 3 years36420 7/1/2004 Y 0 through 1 year36425 7/1/2004 N36430 7/1/2004 N36440 7/1/2004 Y 0 through 2 years36450 7/1/2004 N36455 7/1/2004 N36456 1/1/2017 Y 0 through 4 weeks36460 7/1/2004 Y 12 through 55 years

Page 36 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range36473 1/1/2017 N36474 1/1/2017 N36475 1/1/2005 N36476 1/1/2006 N36478 1/1/2005 N36479 1/1/2006 N36481 7/1/2004 N36482 1/1/2018 N36511 7/1/2004 N36512 7/1/2004 N36513 7/1/2004 N36514 7/1/2004 N36516 7/1/2004 N36522 7/1/2004 N36555 7/1/2004 Y 0 through 5 years36556 7/1/2004 N36557 7/1/2004 Y 0 through 5 years36558 7/1/2004 N36560 7/1/2004 Y 0 through 5 years36561 7/1/2004 N36563 7/1/2004 N36565 7/1/2004 N36566 7/1/2004 N36568 7/1/2004 Y 0 through 5 years36569 7/1/2004 N36570 7/1/2004 Y 0 through 5 years36571 7/1/2004 N36572 1/1/2019 Y 0 through 4 years36573 1/1/2019 Y 5 through 99 years36575 7/1/2004 N36576 7/1/2004 N36578 7/1/2004 N36580 7/1/2004 N36581 7/1/2004 N36582 7/1/2004 N36583 7/1/2004 N36584 7/1/2004 N36585 7/1/2004 N36589 7/1/2004 N36590 7/1/2004 N36593 1/1/2008 N36595 7/1/2004 N36596 7/1/2004 N36597 7/1/2004 N36598 1/1/2006 N36625 1/1/2006 N36640 7/1/2004 N36680 1/1/2006 N36800 7/1/2004 N36810 7/1/2004 N36815 7/1/2004 N36818 1/1/2005 N36819 7/1/2004 N36820 1/1/2006 N

Page 37 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range36821 7/1/2004 N36825 7/1/2004 N36830 7/1/2004 N36831 7/1/2004 N36832 7/1/2004 N36833 7/1/2004 N36835 7/1/2004 N36838 7/1/2004 N36860 7/1/2004 N36861 7/1/2004 N36901 1/1/2017 N36902 1/1/2017 N36903 1/1/2017 N36904 1/1/2017 N36905 1/1/2017 N36906 1/1/2017 N36907 1/1/2017 N36908 1/1/2017 N36909 1/1/2017 N37183 7/1/2004 N37184 1/1/2006 N37185 1/1/2006 N37186 1/1/2006 N37187 1/1/2006 N37188 1/1/2006 N37191 1/1/2012 N37192 1/1/2012 N37193 1/1/2012 N37195 7/1/2004 N37197 1/1/2013 N37200 7/1/2004 N37211 1/1/2013 N37212 1/1/2013 N37213 1/1/2013 N37214 1/1/2013 N37216 1/1/2005 N37220 1/1/2011 N37221 1/1/2011 N37222 1/1/2011 N37223 1/1/2011 N37224 1/1/2011 N37225 1/1/2011 N37226 1/1/2011 N37227 1/1/2011 N37228 1/1/2011 N37229 1/1/2011 N37230 1/1/2011 N37231 1/1/2011 N37232 1/1/2011 N37233 1/1/2011 N37234 1/1/2011 N37235 1/1/2011 N37236 1/1/2014 N37237 1/1/2014 N

Page 38 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range37238 1/1/2014 N37239 1/1/2014 N37246 1/1/2017 N37247 1/1/2017 N37248 1/1/2017 N37249 1/1/2017 N37252 1/1/2016 N37253 1/1/2016 N37500 7/1/2004 N37501 7/1/2004 N37565 1/1/2006 N37600 1/1/2006 N37605 1/1/2006 N37606 1/1/2006 N37607 7/1/2004 N37609 7/1/2004 N37615 1/1/2006 N37619 1/1/2012 N37650 1/1/2006 N37700 7/1/2004 N37718 1/1/2006 N37722 1/1/2006 N37735 7/1/2004 N37760 7/1/2004 N37761 1/1/2010 N37765 7/1/2004 N37766 7/1/2004 N37780 7/1/2004 N37785 7/1/2004 N37790 1/1/2006 N37799 7/1/2004 N38120 1/1/2006 N38129 1/1/2006 N38200 7/1/2004 N38220 1/1/2006 N38221 1/1/2006 N38222 1/1/2018 N38230 7/1/2004 N38232 1/1/2012 N38300 7/1/2004 N38305 7/1/2004 N38308 7/1/2004 N38500 7/1/2004 N38505 7/1/2004 N38510 7/1/2004 N38520 7/1/2004 N38525 7/1/2004 N38530 7/1/2004 N38531 1/1/2019 N38542 7/1/2004 N38550 7/1/2004 N38555 7/1/2004 N38570 7/1/2004 N38571 7/1/2004 N

Page 39 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range38572 7/1/2004 N38573 1/1/2018 N38589 7/1/2004 N38700 7/1/2004 N38720 7/1/2004 N38740 7/1/2004 N38745 7/1/2004 N38760 1/1/2006 N38790 7/1/2004 N38792 7/1/2004 N38794 7/1/2004 N38999 7/1/2004 N39401 1/1/2016 N39402 1/1/2016 N40500 7/1/2004 N40510 7/1/2004 N40520 7/1/2004 N40525 7/1/2004 N40527 7/1/2004 N40530 7/1/2004 N40650 7/1/2004 N40652 7/1/2004 N40654 7/1/2004 N40700 7/1/2004 N40701 7/1/2004 N40702 7/1/2004 N40720 7/1/2004 N40761 7/1/2004 N40799 7/1/2004 N40800 7/1/2004 N40801 7/1/2004 N40804 7/1/2004 N40805 7/1/2004 N40806 7/1/2004 N40808 7/1/2004 N40810 7/1/2004 N40812 7/1/2004 N40814 7/1/2004 N40816 7/1/2004 N40818 7/1/2004 N40819 7/1/2004 N40820 7/1/2004 N40830 7/1/2004 N40831 7/1/2004 N40840 7/1/2004 N40842 7/1/2004 N40843 7/1/2004 N40844 7/1/2004 N40845 7/1/2004 N40899 7/1/2004 N41000 7/1/2004 N41005 7/1/2004 N41006 7/1/2004 N41007 7/1/2004 N

Page 40 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range41008 7/1/2004 N41009 7/1/2004 N41010 7/1/2004 N41015 7/1/2004 N41016 7/1/2004 N41017 7/1/2004 N41018 7/1/2004 N41019 1/1/2008 N41100 7/1/2004 N41105 7/1/2004 N41108 7/1/2004 N41110 7/1/2004 N41112 7/1/2004 N41113 7/1/2004 N41114 7/1/2004 N41115 7/1/2004 N41116 7/1/2004 N41120 7/1/2004 N41250 7/1/2004 N41251 7/1/2004 N41252 7/1/2004 N41510 7/1/2004 N41512 1/1/2009 N41520 7/1/2004 N41530 1/1/2009 N41599 7/1/2004 N41800 7/1/2004 N41805 7/1/2004 N41806 7/1/2004 N41820 7/1/2004 N41821 7/1/2004 N41822 7/1/2004 N41823 7/1/2004 N41825 7/1/2004 N41826 7/1/2004 N41827 7/1/2004 N41828 7/1/2004 N41830 7/1/2004 N41850 7/1/2004 N41870 7/1/2004 N41872 7/1/2004 N41874 7/1/2004 N41899 7/1/2004 N42000 7/1/2004 N42100 7/1/2004 N42104 7/1/2004 N42106 7/1/2004 N42107 7/1/2004 N42120 7/1/2004 N42140 7/1/2004 N42145 7/1/2004 N42160 7/1/2004 N42180 7/1/2004 N42182 7/1/2004 N

Page 41 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range42200 7/1/2004 N42205 7/1/2004 N42210 1/1/2006 N42215 7/1/2004 N42220 7/1/2004 N42225 7/1/2004 N42226 7/1/2004 N42227 7/1/2004 N42235 7/1/2004 N42260 7/1/2004 N42281 7/1/2004 N42299 7/1/2004 N42300 7/1/2004 N42305 7/1/2004 N42310 7/1/2004 N42320 7/1/2004 N42330 7/1/2004 N42335 7/1/2004 N42340 7/1/2004 N42400 7/1/2004 N42405 7/1/2004 N42408 7/1/2004 N42409 7/1/2004 N42410 7/1/2004 N42415 7/1/2004 N42420 7/1/2004 N42425 1/1/2006 N42440 7/1/2004 N42450 7/1/2004 N42500 7/1/2004 N42505 7/1/2004 N42507 7/1/2004 N42508 7/1/2004 N42509 7/1/2004 N42510 7/1/2004 N42550 1/1/2006 N42600 7/1/2004 N42650 7/1/2004 N42660 7/1/2004 N42665 7/1/2004 N42699 7/1/2004 N42700 7/1/2004 N42720 7/1/2004 N42725 7/1/2004 N42800 7/1/2004 N42804 7/1/2004 N42806 7/1/2004 N42808 7/1/2004 N42809 7/1/2004 N42810 7/1/2004 N42815 7/1/2004 N42820 7/1/2004 Y 0 through 11 years42821 7/1/2004 N42825 7/1/2004 Y 0 through 11 years

Page 42 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range42826 7/1/2004 N42830 7/1/2004 Y 0 through 11 years42831 7/1/2004 N42835 7/1/2004 Y 0 through 11 years42836 7/1/2004 N42842 1/1/2006 N42844 1/1/2006 N42860 7/1/2004 N42870 7/1/2004 N42890 7/1/2004 N42892 7/1/2004 N42900 7/1/2004 N42950 1/1/2006 N42955 7/1/2004 N42960 7/1/2004 N42962 7/1/2004 N42970 7/1/2004 N42972 1/1/2006 N42999 7/1/2004 N43020 7/1/2004 N43030 7/1/2004 N43180 1/1/2015 N43191 1/1/2014 N43192 1/1/2014 N43193 1/1/2014 N43194 1/1/2014 N43195 1/1/2014 N43196 1/1/2014 N43197 1/1/2014 N43198 1/1/2014 N43200 7/1/2004 N43201 7/1/2004 N43202 7/1/2004 N43204 7/1/2004 N43205 1/1/2006 N43206 1/1/2013 N43210 1/1/2016 N43211 1/1/2014 N43212 1/1/2014 N43213 1/1/2014 N43214 1/1/2014 N43215 1/1/2006 N43216 1/1/2006 N43217 1/1/2006 N43220 1/1/2006 N43226 1/1/2006 N43227 1/1/2006 N43229 1/1/2014 N43231 1/1/2006 N43232 1/1/2006 N43233 1/1/2014 N43235 7/1/2004 N43236 7/1/2004 N43237 7/1/2004 N

Page 43 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range43238 7/1/2004 N43239 7/1/2004 N43240 1/1/2006 N43241 1/1/2006 N43242 7/1/2004 N43243 7/1/2004 N43244 1/1/2006 N43245 1/1/2006 N43246 1/1/2006 N43247 7/1/2004 N43248 7/1/2004 N43249 7/1/2004 N43250 1/1/2006 N43251 1/1/2006 N43252 1/1/2013 N43253 1/1/2014 N43254 1/1/2014 N43255 1/1/2006 N43257 1/1/2005 N43259 1/1/2006 N43260 1/1/2006 N43261 1/1/2006 N43262 1/1/2006 N43263 1/1/2006 N43264 1/1/2006 N43265 1/1/2006 N43266 1/1/2014 N43270 1/1/2014 N43273 1/1/2009 N43274 1/1/2014 N43275 1/1/2014 N43276 1/1/2014 N43277 1/1/2014 N43278 1/1/2014 N43280 7/1/2004 N43281 1/1/2010 N43284 1/1/2017 N43285 1/1/2017 N43289 7/1/2004 N43420 7/1/2004 N43450 7/1/2004 N43453 7/1/2004 N43510 7/1/2004 N43600 7/1/2004 N43647 1/1/2007 N43648 1/1/2007 Y 18 though 70 years43651 7/1/2004 N43652 7/1/2004 N43653 7/1/2004 N43659 7/1/2004 N43752 7/1/2004 N43753 1/1/2011 N43754 1/1/2011 N43755 1/1/2011 N

Page 44 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range43756 1/1/2011 N43757 1/1/2011 N43761 7/1/2004 N43762 1/1/2019 N43763 1/1/2019 N43770 1/1/2006 N43830 7/1/2004 N43831 7/1/2004 N43842 1/1/2006 N43870 7/1/2004 N43886 1/1/2006 N43887 1/1/2006 N43888 1/1/2006 N44100 7/1/2004 N44180 1/1/2006 N44186 1/1/2006 N44238 7/1/2004 N44312 7/1/2004 N44340 7/1/2004 N44360 7/1/2004 N44361 7/1/2004 N44363 7/1/2004 N44364 7/1/2004 N44365 7/1/2004 N44366 7/1/2004 N44369 7/1/2004 N44370 7/1/2004 N44372 7/1/2004 N44373 7/1/2004 N44376 7/1/2004 N44377 7/1/2004 N44378 7/1/2004 N44379 7/1/2004 N44380 7/1/2004 N44381 1/1/2015 N44382 7/1/2004 N44383 7/1/2004 N44384 1/1/2015 N44385 7/1/2004 N44386 7/1/2004 N44388 7/1/2004 N44389 7/1/2004 N44390 7/1/2004 N44391 7/1/2004 N44392 7/1/2004 N44393 7/1/2004 N44394 7/1/2004 N44397 7/1/2004 N44401 1/1/2015 N44402 1/1/2015 N44403 1/1/2015 N44404 1/1/2015 N44405 1/1/2015 N44406 1/1/2015 N

Page 45 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range44407 1/1/2015 N44408 1/1/2015 N44500 1/1/2006 N44950 7/1/2004 N44970 7/1/2004 N44979 7/1/2004 N45000 7/1/2004 N45005 7/1/2004 N45020 7/1/2004 N45100 7/1/2004 N45108 7/1/2004 N45150 7/1/2004 N45160 7/1/2004 N45171 1/1/2010 N45172 1/1/2010 N45190 7/1/2004 N45300 7/1/2004 N45303 7/1/2004 N45305 7/1/2004 N45307 7/1/2004 N45308 7/1/2004 N45309 7/1/2004 N45315 7/1/2004 N45317 7/1/2004 N45320 7/1/2004 N45321 7/1/2004 N45327 7/1/2004 N45330 7/1/2004 N45331 7/1/2004 N45332 7/1/2004 N45333 7/1/2004 N45334 7/1/2004 N45335 7/1/2004 N45337 7/1/2004 N45338 7/1/2004 N45339 7/1/2004 N45340 7/1/2004 N45341 7/1/2004 N45342 7/1/2004 N45345 7/1/2004 N45346 1/1/2015 N45347 1/1/2015 N45349 1/1/2015 N45350 1/1/2015 N45355 7/1/2004 N45378 7/1/2004 N45379 7/1/2004 N45380 7/1/2004 N45381 7/1/2004 N45382 7/1/2004 N45383 7/1/2004 N45384 7/1/2004 N45385 7/1/2004 N45386 7/1/2004 N

Page 46 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range45387 7/1/2004 N45388 1/1/2015 N45389 1/1/2015 N45390 1/1/2015 N45391 1/1/2005 N45392 1/1/2005 N45393 1/1/2015 N45398 1/1/2015 N45499 1/1/2006 N45500 7/1/2004 N45505 7/1/2004 N45520 7/1/2004 N45541 1/1/2006 N45560 7/1/2004 N45900 7/1/2004 N45905 7/1/2004 N45910 7/1/2004 N45915 7/1/2004 N45990 1/1/2006 N45999 7/1/2004 N46020 7/1/2004 N46030 7/1/2004 N46040 7/1/2004 N46045 7/1/2004 N46050 7/1/2004 N46060 7/1/2004 N46070 7/1/2004 Y 0 through 1 year46080 7/1/2004 N46083 7/1/2004 N46200 7/1/2004 N46220 7/1/2004 N46221 1/1/2011 N46230 7/1/2004 N46250 7/1/2004 N46255 7/1/2004 N46257 7/1/2004 N46258 7/1/2004 N46260 7/1/2004 N46261 7/1/2004 N46262 7/1/2004 N46270 7/1/2004 N46275 7/1/2004 N46280 7/1/2004 N46285 7/1/2004 N46288 7/1/2004 N46320 7/1/2004 N46500 7/1/2004 N46505 1/1/2006 N46604 7/1/2004 N46606 7/1/2004 N46608 7/1/2004 N46610 7/1/2004 N46611 7/1/2004 N46612 7/1/2004 N

Page 47 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range46614 7/1/2004 N46615 7/1/2004 N46700 7/1/2004 N46706 7/1/2004 N46707 1/1/2010 N46750 7/1/2004 N46753 7/1/2004 N46754 7/1/2004 N46760 7/1/2004 N46761 7/1/2004 N46910 7/1/2004 N46916 7/1/2004 N46917 7/1/2004 N46922 7/1/2004 N46924 7/1/2004 N46930 1/1/2009 N46940 7/1/2004 N46942 7/1/2004 N46945 7/1/2004 N46946 7/1/2004 N46947 1/1/2005 N46999 7/1/2004 N47000 7/1/2004 N47001 1/1/2006 N47370 7/1/2004 N47371 7/1/2004 N47379 7/1/2004 N47382 7/1/2004 N47399 7/1/2004 N47490 7/1/2004 N47531 1/1/2016 N47532 1/1/2016 N47533 1/1/2016 N47534 1/1/2016 N47535 1/1/2016 N47536 1/1/2016 N47537 1/1/2016 N47538 1/1/2016 N47539 1/1/2016 N47540 1/1/2016 N47541 1/1/2016 N47542 1/1/2016 N47543 1/1/2016 N47544 1/1/2016 N47552 7/1/2004 N47553 7/1/2004 N47554 7/1/2004 N47555 7/1/2004 N47556 7/1/2004 N47562 7/1/2004 N47563 7/1/2004 N47564 7/1/2004 N47579 7/1/2004 N47999 7/1/2004 N

Page 48 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range48102 7/1/2004 N48550 1/1/2006 N49082 1/1/2012 N49083 1/1/2012 N49084 1/1/2012 N49180 7/1/2004 N49185 1/1/2016 N49250 7/1/2004 N49320 7/1/2004 N49321 7/1/2004 N49322 7/1/2004 N49323 7/1/2004 N49324 1/1/2007 N49325 1/1/2007 N49326 1/1/2007 N49327 1/1/2011 N49329 7/1/2004 N49400 7/1/2004 N49402 1/1/2007 N49405 1/1/2014 N49406 1/1/2014 N49407 1/1/2014 N49411 1/1/2010 N49418 1/1/2011 N49419 7/1/2004 N49421 7/1/2004 N49422 7/1/2004 N49423 7/1/2004 N49424 7/1/2004 N49426 7/1/2004 N49427 7/1/2004 N49429 7/1/2004 N49435 1/1/2007 N49436 1/1/2007 N49440 1/1/2008 N49441 1/1/2008 N49442 1/1/2008 N49446 1/1/2008 N49450 1/1/2008 N49451 1/1/2008 N49452 1/1/2008 N49460 1/1/2008 N49465 1/1/2008 N49491 7/1/2004 Y 0 through 5 months49492 1/1/2006 Y 0 through 5 months49495 7/1/2004 Y 0 through 5 months49496 7/1/2004 Y 0 through 5 months49500 7/1/2004 Y 6 through 59 months49501 7/1/2004 Y 6 through 59 months49505 7/1/2004 N49507 7/1/2004 N49520 7/1/2004 N49521 7/1/2004 N49525 7/1/2004 N

Page 49 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range49540 7/1/2004 N49550 7/1/2004 N49553 7/1/2004 N49555 7/1/2004 N49557 7/1/2004 N49560 7/1/2004 N49561 7/1/2004 N49565 7/1/2004 N49566 7/1/2004 N49568 1/1/2006 N49570 7/1/2004 N49572 7/1/2004 N49580 7/1/2004 Y 0 through 4 years49582 7/1/2004 Y 0 through 4 years49585 7/1/2004 N49587 7/1/2004 N49590 7/1/2004 N49600 7/1/2004 N49650 7/1/2004 N49651 7/1/2004 N49652 1/1/2009 N49653 1/1/2009 N49654 1/1/2009 N49655 1/1/2009 N49656 1/1/2009 N49657 1/1/2009 N49659 7/1/2004 N49999 7/1/2004 N50020 7/1/2004 N50080 7/1/2004 N50081 7/1/2004 N50200 7/1/2004 N50382 1/1/2006 N50384 1/1/2006 N50385 1/1/2008 N50386 1/1/2008 N50387 1/1/2006 N50389 1/1/2006 N50390 7/1/2004 N50391 1/1/2005 N50396 7/1/2004 N50430 1/1/2016 N50431 1/1/2016 N50432 1/1/2016 N50433 1/1/2016 N50434 1/1/2016 N50435 1/1/2016 N50436 1/1/2019 N50437 1/1/2019 N50541 7/1/2004 N50542 7/1/2004 N50543 7/1/2004 N50544 7/1/2004 N50549 7/1/2004 N

Page 50 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range50551 7/1/2004 N50553 7/1/2004 N50555 7/1/2004 N50557 7/1/2004 N50561 7/1/2004 N50562 7/1/2004 N50570 7/1/2004 N50572 7/1/2004 N50574 7/1/2004 N50575 7/1/2004 N50576 7/1/2004 N50580 7/1/2004 N50590 7/1/2004 N50592 1/1/2006 N50593 1/1/2008 N50606 1/1/2016 N50684 7/1/2004 N50686 7/1/2004 N50688 7/1/2004 N50690 7/1/2004 N50693 1/1/2016 N50694 1/1/2016 N50695 1/1/2016 N50705 1/1/2016 N50706 1/1/2016 N50727 7/1/2004 N50945 7/1/2004 N50947 7/1/2004 N50948 7/1/2004 N50949 7/1/2004 N50951 7/1/2004 N50953 7/1/2004 N50955 7/1/2004 N50957 7/1/2004 N50961 7/1/2004 N50970 7/1/2004 N50972 7/1/2004 N50974 7/1/2004 N50976 7/1/2004 N50980 7/1/2004 N51020 7/1/2004 N51030 7/1/2004 N51040 7/1/2004 N51045 7/1/2004 N51050 7/1/2004 N51060 7/1/2004 N51065 7/1/2004 N51080 7/1/2004 N51100 1/1/2008 N51101 1/1/2008 N51102 1/1/2008 N51500 7/1/2004 N51520 7/1/2004 N51535 7/1/2004 N

Page 51 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range51600 7/1/2004 N51605 7/1/2004 N51610 7/1/2004 N51705 7/1/2004 N51710 7/1/2004 N51715 7/1/2004 N51720 7/1/2004 N51725 7/1/2004 N51726 7/1/2004 N51727 1/1/2010 N51728 1/1/2010 N51729 1/1/2010 N51736 7/1/2004 N51741 7/1/2004 N51784 7/1/2004 N51785 7/1/2004 N51792 7/1/2004 N51797 7/1/2004 N51798 7/1/2004 N51845 1/1/2006 N51860 1/1/2006 N51880 7/1/2004 N51990 7/1/2004 N51992 7/1/2004 N51999 1/1/2006 N52000 7/1/2004 N52001 7/1/2004 N52005 7/1/2004 N52007 7/1/2004 N52010 7/1/2004 N52204 7/1/2004 N52214 7/1/2004 N52224 7/1/2004 N52234 7/1/2004 N52235 7/1/2004 N52240 7/1/2004 N52250 7/1/2004 N52260 7/1/2004 N52265 7/1/2004 N52270 7/1/2004 N52275 7/1/2004 N52276 7/1/2004 N52277 7/1/2004 N52281 7/1/2004 N52282 7/1/2004 N52283 7/1/2004 N52285 7/1/2004 N52287 1/1/2013 N52290 7/1/2004 N52300 7/1/2004 N52301 7/1/2004 N52305 7/1/2004 N52310 7/1/2004 N52315 7/1/2004 N

Page 52 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range52317 7/1/2004 N52318 7/1/2004 N52320 7/1/2004 N52325 7/1/2004 N52327 7/1/2004 N52330 7/1/2004 N52332 7/1/2004 N52334 7/1/2004 N52341 7/1/2004 N52342 7/1/2004 N52343 7/1/2004 N52344 7/1/2004 N52345 7/1/2004 N52346 7/1/2004 N52351 7/1/2004 N52352 7/1/2004 N52353 7/1/2004 N52354 7/1/2004 N52355 7/1/2004 N52356 1/1/2014 N52400 7/1/2004 N52402 1/1/2005 N52441 1/1/2015 N52442 1/1/2015 N52450 7/1/2004 N52500 7/1/2004 N52601 7/1/2004 N52630 7/1/2004 N52640 7/1/2004 N52647 7/1/2004 N52648 7/1/2004 N52649 1/1/2008 N52700 7/1/2004 N53000 7/1/2004 N53010 7/1/2004 N53020 7/1/2004 N53025 7/1/2004 N53040 7/1/2004 N53060 7/1/2004 N53080 7/1/2004 N53085 7/1/2004 N53200 7/1/2004 N53210 1/1/2006 N53215 1/1/2006 N53220 1/1/2006 N53230 7/1/2004 N53235 7/1/2004 N53240 7/1/2004 N53250 7/1/2004 N53260 7/1/2004 N53265 7/1/2004 N53270 7/1/2004 N53275 7/1/2004 N53400 7/1/2004 N

Page 53 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range53405 7/1/2004 N53410 7/1/2004 N53420 7/1/2004 N53425 7/1/2004 N53430 7/1/2004 N53431 7/1/2004 N53440 7/1/2004 N53442 7/1/2004 N53444 7/1/2004 N53445 7/1/2004 N53446 7/1/2004 N53447 7/1/2004 N53449 7/1/2004 N53450 7/1/2004 N53460 7/1/2004 N53500 7/1/2004 N53502 7/1/2004 N53505 7/1/2004 N53510 7/1/2004 N53515 7/1/2004 N53520 7/1/2004 N53600 7/1/2004 N53601 7/1/2004 N53605 7/1/2004 N53620 7/1/2004 N53621 7/1/2004 N53660 7/1/2004 N53661 7/1/2004 N53665 7/1/2004 N53850 7/1/2004 N53852 7/1/2004 N53854 1/1/2019 N53855 1/1/2010 N53860 1/1/2011 N53899 7/1/2004 N54000 7/1/2004 Y 0 through 1 year54001 7/1/2004 N54015 7/1/2004 N54057 7/1/2004 N54060 7/1/2004 N54065 7/1/2004 N54100 7/1/2004 N54105 7/1/2004 N54110 7/1/2004 N54111 7/1/2004 N54112 7/1/2004 N54115 7/1/2004 N54120 1/1/2006 N54150 7/1/2004 N54160 7/1/2004 Y 0 through 1 year54161 7/1/2004 N54162 7/1/2004 N54163 7/1/2004 N54164 7/1/2004 N

Page 54 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range54200 7/1/2004 N54205 7/1/2004 N54220 7/1/2004 N54230 7/1/2004 N54300 7/1/2004 N54304 7/1/2004 N54308 7/1/2004 N54312 7/1/2004 N54316 7/1/2004 N54318 7/1/2004 N54322 7/1/2004 N54324 7/1/2004 N54326 7/1/2004 N54328 7/1/2004 N54332 7/1/2004 N54336 7/1/2004 N54340 7/1/2004 N54344 7/1/2004 N54348 7/1/2004 N54352 7/1/2004 N54360 1/1/2006 Y 0 through 20 years54380 7/1/2004 N54385 7/1/2004 N54420 7/1/2004 N54435 7/1/2004 N54437 1/1/2016 N54440 7/1/2004 N54500 7/1/2004 N54505 7/1/2004 N54512 7/1/2004 N54520 7/1/2004 N54522 7/1/2004 N54530 1/1/2005 N54550 7/1/2004 N54560 7/1/2004 N54600 7/1/2004 N54620 7/1/2004 N54640 7/1/2004 N54650 7/1/2004 N54670 7/1/2004 N54680 1/1/2006 N54690 7/1/2004 N54692 7/1/2004 N54699 7/1/2004 N54700 7/1/2004 N54800 7/1/2004 N54830 7/1/2004 N54840 7/1/2004 N54860 7/1/2004 N54861 7/1/2004 N54865 1/1/2007 N54900 1/1/2006 N54901 1/1/2006 N55000 7/1/2004 N

Page 55 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range55040 7/1/2004 N55041 7/1/2004 N55060 7/1/2004 N55100 7/1/2004 N55110 7/1/2004 N55120 7/1/2004 N55150 1/1/2006 N55175 7/1/2004 N55180 1/1/2006 N55200 7/1/2004 N55250 1/1/2006 Y 21 through 65 years55300 7/1/2004 N55400 7/1/2004 N55500 7/1/2004 N55520 7/1/2004 N55530 7/1/2004 N55535 7/1/2004 N55540 7/1/2004 N55550 7/1/2004 N55559 7/1/2004 N55600 7/1/2004 N55680 7/1/2004 N55700 7/1/2004 N55705 7/1/2004 N55706 1/1/2009 N55720 7/1/2004 N55725 7/1/2004 N55860 7/1/2004 N55873 7/1/2004 N55874 1/1/2018 N55875 1/1/2007 N55876 1/1/2007 N55899 3/1/2007 N55920 1/1/2008 N56405 7/1/2004 N56420 7/1/2004 N56440 7/1/2004 N56441 7/1/2004 N56442 1/1/2007 N56501 7/1/2004 N56515 7/1/2004 N56605 7/1/2004 N56606 1/1/2006 N56620 7/1/2004 N56625 1/1/2006 N56740 7/1/2004 N56800 7/1/2004 N56805 1/1/2006 N56810 7/1/2004 N57000 7/1/2004 N57010 7/1/2004 N57020 7/1/2004 N57022 7/1/2004 Y 12 through 55 years57023 7/1/2004 N

Page 56 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range57061 7/1/2004 N57065 7/1/2004 N57105 7/1/2004 N57106 7/1/2004 N57107 1/1/2006 N57109 1/1/2006 N57120 1/1/2006 N57130 7/1/2004 N57135 7/1/2004 N57200 7/1/2004 N57210 7/1/2004 N57220 7/1/2004 N57230 7/1/2004 N57240 7/1/2004 N57250 7/1/2004 N57260 7/1/2004 N57265 7/1/2004 N57267 1/1/2006 N57268 7/1/2004 N57282 7/1/2004 N57283 1/1/2005 N57284 7/1/2004 N57285 1/1/2008 N57287 7/1/2004 N57288 7/1/2004 N57289 7/1/2004 N57291 1/1/2006 Y 0 through 14 years57292 1/1/2006 N57295 1/1/2006 N57300 7/1/2004 N57310 7/1/2004 N57320 7/1/2004 N57330 7/1/2004 N57335 1/1/2006 N57400 7/1/2004 N57410 7/1/2004 N57415 7/1/2004 N57423 1/1/2008 N57425 7/1/2004 N57426 1/1/2010 N57454 7/1/2004 N57455 7/1/2004 N57456 1/1/2006 N57460 1/1/2006 N57461 7/1/2004 N57505 7/1/2004 N57510 1/1/2006 N57511 1/1/2006 N57513 7/1/2004 N57520 7/1/2004 N57522 7/1/2004 N57530 7/1/2004 N57550 7/1/2004 N57555 7/1/2004 N

Page 57 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range57556 7/1/2004 N57558 1/1/2007 N57700 7/1/2004 N57720 7/1/2004 N57800 10/1/2005 N58100 1/1/2006 N58110 1/1/2006 N58120 7/1/2004 N58145 7/1/2004 N58260 7/1/2004 N58262 7/1/2004 N58263 7/1/2004 N58270 7/1/2004 N58290 7/1/2004 N58291 7/1/2004 N58292 7/1/2004 N58294 7/1/2004 N58346 1/1/2006 N58353 7/1/2004 N58356 1/1/2005 N58541 1/1/2007 N58542 1/1/2007 N58543 1/1/2007 N58544 1/1/2007 N58545 7/1/2004 N58546 7/1/2004 N58550 7/1/2004 N58552 7/1/2004 N58553 7/1/2004 N58554 7/1/2004 N58555 7/1/2004 N58558 7/1/2004 N58559 7/1/2004 N58560 7/1/2004 N58561 7/1/2004 N58562 7/1/2004 N58563 7/1/2004 N58565 1/1/2005 Y 21 through 60 years58570 1/1/2008 N58571 1/1/2008 N58572 1/1/2008 N58573 1/1/2008 N58578 7/1/2004 N58579 7/1/2004 N58600 7/1/2004 Y 21 through 55 years58615 7/1/2004 Y 21 through 55 years58660 7/1/2004 N58661 7/1/2004 N58662 7/1/2004 N58670 7/1/2004 Y 21 through 55 years58671 7/1/2004 Y 21 through 55 years58673 7/1/2004 N58674 1/1/2017 N58679 7/1/2004 N

Page 58 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range58770 7/1/2004 N58800 7/1/2004 N58805 7/1/2004 N58820 7/1/2004 N58900 7/1/2004 N58920 7/1/2004 N58925 7/1/2004 N59000 7/1/2004 Y 12 through 55 years59001 7/1/2004 Y 12 through 55 years59012 7/1/2004 Y 12 through 55 years59015 7/1/2004 Y 12 through 55 years59020 7/1/2004 Y 12 through 55 years59025 7/1/2004 Y 12 through 55 years59030 7/1/2004 Y 12 through 55 years59070 7/1/2004 Y 10 through 60 years59074 7/1/2004 Y 10 through 60 years59076 7/1/2004 Y 10 through 55 years59100 1/1/2006 Y 12 through 55 years59150 7/1/2004 Y 12 through 55 years59151 7/1/2004 Y 12 through 55 years59160 7/1/2004 Y 12 through 55 years59320 1/1/2005 Y 10 through 60 years59412 7/1/2004 Y 10 through 55 years59812 7/1/2004 Y 10 through 60 years59820 7/1/2004 Y 10 through 60 years59821 7/1/2004 Y 10 through 60 years59840 7/1/2004 Y 10 through 60 years59841 7/1/2004 Y 10 through 60 years59870 7/1/2004 Y 10 through 60 years59871 7/1/2004 Y 10 through 60 years59897 7/1/2004 Y 10 through 60 years60000 7/1/2004 N60100 7/1/2004 N60200 7/1/2004 N60210 7/1/2004 N60212 7/1/2004 N60220 7/1/2004 N60225 7/1/2004 N60240 7/1/2004 N60252 1/1/2006 N60260 7/1/2004 N60271 7/1/2004 N60280 7/1/2004 N60281 7/1/2004 N60300 1/1/2008 N60500 7/1/2004 N60502 7/1/2004 N60512 1/1/2006 N60520 7/1/2004 N60659 7/1/2004 N60699 7/1/2004 N61000 7/1/2004 Y 0 through 2 years61001 7/1/2004 Y 0 through 2 years61020 7/1/2004 N

Page 59 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range61026 7/1/2004 N61050 7/1/2004 N61055 7/1/2004 N61070 7/1/2004 N61215 7/1/2004 N61334 7/1/2004 N61623 1/1/2006 N61626 7/1/2004 N61640 1/1/2006 N61641 1/1/2006 N61642 1/1/2006 N61770 7/1/2004 N61781 1/1/2011 N61782 1/1/2011 N61783 1/1/2011 N61790 7/1/2004 N61791 7/1/2004 N61796 1/1/2009 N61797 1/1/2009 N61798 1/1/2009 N61799 1/1/2009 N61800 1/1/2009 N61880 7/1/2004 N61885 1/1/2005 N61886 7/1/2004 N61888 7/1/2004 N62160 1/1/2006 N62194 7/1/2004 N62225 7/1/2004 N62230 7/1/2004 N62264 1/1/2006 N62267 1/1/2009 N62268 7/1/2004 N62269 7/1/2004 N62270 7/1/2004 N62272 7/1/2004 N62273 1/1/2006 N62280 7/1/2004 N62281 1/1/2006 N62282 1/1/2006 N62287 1/1/2008 N62290 7/1/2004 N62291 7/1/2004 N62292 7/1/2004 N62294 7/1/2004 N62320 1/1/2017 N62321 1/1/2017 N62322 1/1/2017 N62323 1/1/2017 N62324 1/1/2017 N62325 1/1/2017 N62326 1/1/2017 N62327 1/1/2017 N62350 7/1/2004 N

Page 60 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range62351 7/1/2004 N62355 7/1/2004 N62360 7/1/2004 N62361 7/1/2004 N62362 7/1/2004 N62365 7/1/2004 N63001 7/1/2004 N63003 7/1/2004 N63005 7/1/2004 N63011 7/1/2004 N63012 7/1/2004 N63015 7/1/2004 N63016 7/1/2004 N63017 7/1/2004 N63020 7/1/2004 N63030 7/1/2004 N63035 1/1/2006 N63040 7/1/2004 N63042 7/1/2004 N63045 7/1/2004 N63046 7/1/2004 N63047 7/1/2004 N63048 1/1/2006 N63055 7/1/2004 N63056 7/1/2004 N63064 7/1/2004 N63075 7/1/2004 N63600 1/1/2006 N63610 7/1/2004 N63620 1/1/2009 N63621 1/1/2009 N63650 7/1/2004 N63655 7/1/2004 N63661 1/1/2010 N63662 1/1/2010 N63663 1/1/2010 N63664 1/1/2010 N63685 1/1/2005 N63688 7/1/2004 N63741 7/1/2004 N63744 7/1/2004 N63746 7/1/2004 N64400 7/1/2004 N64402 7/1/2004 N64405 7/1/2004 N64408 7/1/2004 N64410 7/1/2004 N64413 7/1/2004 N64415 7/1/2004 N64416 7/1/2004 N64417 7/1/2004 N64418 7/1/2004 N64420 7/1/2004 N64421 7/1/2004 N

Page 61 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range64425 7/1/2004 N64430 7/1/2004 N64435 7/1/2004 N64445 7/1/2004 N64446 7/1/2004 N64447 7/1/2004 N64448 7/1/2004 N64449 7/1/2004 N64450 7/1/2004 N64455 1/1/2009 N64461 1/1/2016 N64462 1/1/2016 N64463 1/1/2016 N64479 1/1/2006 N64480 1/1/2006 N64483 1/1/2006 N64484 1/1/2006 N64486 1/1/2015 N64487 1/1/2015 N64488 1/1/2015 N64489 1/1/2015 N64490 1/1/2010 N64491 1/1/2010 N64492 1/1/2010 N64493 1/1/2010 N64494 1/1/2010 N64495 1/1/2010 N64505 1/1/2006 N64510 7/1/2004 N64517 7/1/2004 N64520 1/1/2006 N64530 7/1/2004 N64553 7/1/2004 N64555 7/1/2004 N64561 7/1/2004 N64568 1/1/2011 N64569 1/1/2011 N64570 1/1/2011 N64575 7/1/2004 N64580 7/1/2004 N64581 7/1/2004 N64585 7/1/2004 N64590 1/1/2005 N64595 7/1/2004 N64600 1/1/2006 N64605 7/1/2004 N64610 1/1/2006 N64611 1/1/2011 N64612 7/1/2004 N64615 1/1/2013 N64616 1/1/2014 N64617 1/1/2014 N64620 7/1/2004 N64630 7/1/2004 N

Page 62 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range64632 1/1/2009 N64633 1/1/2012 N64634 1/1/2012 N64635 1/1/2012 N64636 1/1/2012 N64640 7/1/2004 N64642 1/1/2014 N64643 1/1/2014 N64644 1/1/2014 N64645 1/1/2014 N64646 1/1/2014 N64647 1/1/2014 N64650 1/1/2006 N64653 1/1/2006 N64680 1/1/2006 N64681 1/1/2006 N64702 7/1/2004 N64704 7/1/2004 N64708 7/1/2004 N64712 7/1/2004 N64713 7/1/2004 N64714 7/1/2004 N64716 7/1/2004 N64718 7/1/2004 N64719 7/1/2004 N64721 7/1/2004 N64722 7/1/2004 N64726 7/1/2004 N64727 7/1/2004 N64732 7/1/2004 N64734 7/1/2004 N64736 7/1/2004 N64738 7/1/2004 N64740 7/1/2004 N64742 7/1/2004 N64744 7/1/2004 N64746 7/1/2004 N64761 7/1/2004 N64763 7/1/2004 N64766 1/1/2006 N64771 7/1/2004 N64772 7/1/2004 N64774 7/1/2004 N64776 7/1/2004 N64778 1/1/2006 N64782 7/1/2004 N64783 1/1/2006 N64784 7/1/2004 N64786 7/1/2004 N64788 7/1/2004 N64790 7/1/2004 N64792 1/1/2006 N64795 7/1/2004 N64802 7/1/2004 N

Page 63 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range64804 7/1/2004 N64820 7/1/2004 N64821 7/1/2004 N64822 7/1/2004 N64823 7/1/2004 N64831 7/1/2004 N64832 1/1/2006 N64834 7/1/2004 N64835 7/1/2004 N64836 7/1/2004 N64837 1/1/2006 N64840 7/1/2004 N64856 7/1/2004 N64857 7/1/2004 N64858 7/1/2004 N64859 1/1/2006 N64861 7/1/2004 N64862 7/1/2004 N64864 7/1/2004 N64865 7/1/2004 N64870 7/1/2004 N64872 1/1/2006 N64874 1/1/2006 N64876 1/1/2006 N64885 7/1/2004 N64886 7/1/2004 N64890 7/1/2004 N64891 7/1/2004 N64892 7/1/2004 N64893 7/1/2004 N64895 7/1/2004 N64896 7/1/2004 N64897 7/1/2004 N64898 7/1/2004 N64901 1/1/2006 N64902 1/1/2006 N64905 7/1/2004 N64907 7/1/2004 N64910 1/1/2007 N64911 1/1/2007 N64912 1/1/2018 N64999 7/1/2004 N65091 7/1/2004 N65093 7/1/2004 N65101 7/1/2004 N65103 7/1/2004 N65105 7/1/2004 N65110 1/1/2006 N65112 1/1/2006 N65114 1/1/2006 N65125 7/1/2004 N65130 7/1/2004 N65135 7/1/2004 N65140 7/1/2004 N

Page 64 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range65150 7/1/2004 N65155 7/1/2004 N65175 7/1/2004 N65235 7/1/2004 N65260 7/1/2004 N65265 7/1/2004 N65270 7/1/2004 N65272 1/1/2006 N65275 7/1/2004 N65280 7/1/2004 N65285 7/1/2004 N65286 7/1/2004 N65290 7/1/2004 N65400 7/1/2004 N65410 7/1/2004 N65420 7/1/2004 N65426 7/1/2004 N65430 1/1/2006 N65435 7/1/2004 N65436 7/1/2004 N65450 7/1/2004 N65600 7/1/2004 N65710 7/1/2004 N65730 7/1/2004 N65750 7/1/2004 N65755 7/1/2004 N65756 1/1/2009 N65760 7/1/2004 N65765 7/1/2004 N65767 7/1/2004 N65770 7/1/2004 N65772 5/1/2005 N65775 7/1/2004 N65779 1/1/2011 N65780 7/1/2004 N65781 7/1/2004 N65782 7/1/2004 N65785 1/1/2016 N65800 7/1/2004 N65810 7/1/2004 N65815 7/1/2004 N65820 7/1/2004 N65850 7/1/2004 N65855 5/1/2005 N65860 7/1/2004 N65865 7/1/2004 N65870 7/1/2004 N65875 7/1/2004 N65880 7/1/2004 N65900 7/1/2004 N65920 7/1/2004 N65930 7/1/2004 N66020 7/1/2004 N66030 7/1/2004 N

Page 65 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range66130 7/1/2004 N66150 7/1/2004 N66155 7/1/2004 N66160 7/1/2004 N66165 7/1/2004 N66170 7/1/2004 N66172 7/1/2004 N66174 1/1/2011 N66175 1/1/2011 N66179 1/1/2015 N66180 7/1/2004 N66183 1/1/2014 N66184 1/1/2015 N66185 7/1/2004 N66225 7/1/2004 N66250 7/1/2004 N66500 7/1/2004 N66505 7/1/2004 N66600 7/1/2004 N66605 7/1/2004 N66625 7/1/2004 N66630 7/1/2004 N66635 7/1/2004 N66680 7/1/2004 N66682 7/1/2004 N66700 7/1/2004 N66710 7/1/2004 N66711 1/1/2005 N66720 7/1/2004 N66740 7/1/2004 N66761 5/1/2005 N66762 7/1/2004 N66770 7/1/2004 N66820 7/1/2004 N66821 5/1/2005 N66825 7/1/2004 N66830 7/1/2004 N66840 5/1/2005 N66850 5/1/2005 N66852 5/1/2005 N66920 5/1/2005 N66930 5/1/2005 N66940 5/1/2005 N66982 5/1/2005 N66983 5/1/2005 N66984 5/1/2005 N66985 5/1/2005 N66986 5/1/2005 N66999 7/1/2004 N67005 7/1/2004 N67010 7/1/2004 N67015 7/1/2004 N67025 7/1/2004 N67027 7/1/2004 N

Page 66 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range67028 7/1/2004 N67030 7/1/2004 N67031 7/1/2004 N67036 7/1/2004 N67039 7/1/2004 N67040 7/1/2004 N67041 1/1/2008 N67042 1/1/2008 N67043 1/1/2008 N67101 7/1/2004 N67105 7/1/2004 N67107 7/1/2004 N67108 7/1/2004 N67110 7/1/2004 N67113 1/1/2008 N67115 7/1/2004 N67120 7/1/2004 N67121 7/1/2004 N67141 7/1/2004 N67145 7/1/2004 N67208 7/1/2004 N67210 7/1/2004 N67218 7/1/2004 N67220 7/1/2004 N67221 7/1/2004 N67225 7/1/2004 N67227 7/1/2004 N67228 7/1/2004 N67229 1/1/2008 N67250 7/1/2004 N67255 7/1/2004 N67299 7/1/2004 N67311 7/1/2004 N67312 7/1/2004 N67314 7/1/2004 N67316 7/1/2004 N67318 7/1/2004 N67320 1/1/2006 N67331 1/1/2006 N67332 1/1/2006 N67334 1/1/2006 N67340 1/1/2006 N67343 7/1/2004 N67345 7/1/2004 N67346 1/1/2007 N67399 7/1/2004 N67400 7/1/2004 N67405 7/1/2004 N67412 7/1/2004 N67413 7/1/2004 N67414 7/1/2004 N67415 7/1/2004 N67420 7/1/2004 N67430 7/1/2004 N

Page 67 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range67440 7/1/2004 N67445 7/1/2004 N67450 7/1/2004 N67500 7/1/2004 N67505 7/1/2004 N67515 7/1/2004 N67550 7/1/2004 N67560 7/1/2004 N67570 7/1/2004 N67599 7/1/2004 N67700 7/1/2004 N67710 7/1/2004 N67715 7/1/2004 N67800 3/1/2007 N67801 7/1/2004 N67805 7/1/2004 N67808 7/1/2004 N67810 7/1/2004 N67835 7/1/2004 N67840 7/1/2004 N67850 7/1/2004 N67875 7/1/2004 N67880 7/1/2004 N67882 7/1/2004 N67900 7/1/2004 N67901 7/1/2004 N67902 7/1/2004 N67903 7/1/2004 N67904 7/1/2004 N67906 7/1/2004 N67908 7/1/2004 N67909 7/1/2004 N67911 7/1/2004 N67912 7/1/2004 N67914 7/1/2004 N67915 7/1/2004 N67916 7/1/2004 N67917 7/1/2004 N67921 7/1/2004 N67922 7/1/2004 N67923 7/1/2004 N67924 7/1/2004 N67930 7/1/2004 N67935 7/1/2004 N67938 7/1/2004 N67950 7/1/2004 N67961 7/1/2004 N67966 7/1/2004 N67971 7/1/2004 N67973 7/1/2004 N67974 7/1/2004 N67975 7/1/2004 N67999 7/1/2004 N68020 1/1/2006 N

Page 68 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range68040 1/1/2006 N68100 7/1/2004 N68110 7/1/2004 N68115 7/1/2004 N68130 7/1/2004 N68135 1/1/2006 N68320 7/1/2004 N68325 7/1/2004 N68326 7/1/2004 N68328 7/1/2004 N68330 7/1/2004 N68335 7/1/2004 N68340 7/1/2004 N68360 7/1/2004 N68362 7/1/2004 N68371 1/1/2006 N68399 7/1/2004 N68400 7/1/2004 N68420 7/1/2004 N68440 7/1/2004 N68500 7/1/2004 N68505 7/1/2004 N68510 7/1/2004 N68520 7/1/2004 N68525 7/1/2004 N68530 7/1/2004 N68540 7/1/2004 N68550 7/1/2004 N68700 7/1/2004 N68705 7/1/2004 N68720 7/1/2004 N68745 7/1/2004 N68750 7/1/2004 N68760 7/1/2004 N68761 5/1/2005 N68770 7/1/2004 N68801 5/1/2005 N68810 1/1/2006 N68811 7/1/2004 N68815 7/1/2004 N68816 1/1/2008 N68840 7/1/2004 N68850 7/1/2004 N68899 7/1/2004 N69000 7/1/2004 N69005 7/1/2004 N69020 7/1/2004 N69100 7/1/2004 N69105 7/1/2004 N69110 7/1/2004 N69120 7/1/2004 N69140 7/1/2004 N69145 7/1/2004 N69150 7/1/2004 N

Page 69 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range69205 7/1/2004 N69220 7/1/2004 N69222 1/1/2006 N69310 7/1/2004 N69320 7/1/2004 N69399 7/1/2004 N69400 7/1/2004 N69401 7/1/2004 N69405 7/1/2004 N69420 7/1/2004 N69421 7/1/2004 N69424 7/1/2004 N69433 7/1/2004 N69436 7/1/2004 N69440 7/1/2004 N69450 7/1/2004 N69501 7/1/2004 N69502 7/1/2004 N69505 1/1/2006 N69511 1/1/2006 N69530 1/1/2006 N69540 7/1/2004 N69550 7/1/2004 N69552 7/1/2004 N69601 7/1/2004 N69602 7/1/2004 N69603 1/1/2006 N69604 7/1/2004 N69605 7/1/2004 N69610 7/1/2004 N69620 7/1/2004 N69631 7/1/2004 N69632 7/1/2004 N69633 7/1/2004 N69635 7/1/2004 N69636 7/1/2004 N69637 7/1/2004 N69641 7/1/2004 N69642 7/1/2004 N69643 7/1/2004 N69644 7/1/2004 N69645 1/1/2006 N69646 1/1/2006 N69650 7/1/2004 N69660 7/1/2004 N69661 7/1/2004 N69662 7/1/2004 N69666 7/1/2004 N69667 7/1/2004 N69670 7/1/2004 N69676 7/1/2004 N69700 7/1/2004 N69710 7/1/2004 N69711 7/1/2004 N

Page 70 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range69714 7/1/2004 N69715 7/1/2004 N69717 7/1/2004 N69718 7/1/2004 N69720 7/1/2004 N69725 7/1/2004 N69740 7/1/2004 N69745 7/1/2004 N69799 7/1/2004 N69801 7/1/2004 N69805 7/1/2004 N69806 7/1/2004 N69820 7/1/2004 N69905 1/1/2006 N69910 1/1/2006 N69915 1/1/2006 N69930 7/1/2004 N69949 1/1/2006 N69955 7/1/2004 N69960 7/1/2004 N69970 1/1/2006 N69979 7/1/2004 N70010 7/1/2004 N70015 7/1/2004 N70336 7/1/2004 N70371 1/1/2006 N70390 7/1/2004 N70450 7/1/2004 N70460 7/1/2004 N70470 7/1/2004 N70480 7/1/2004 N70481 7/1/2004 N70482 7/1/2004 N70486 7/1/2004 N70487 7/1/2004 N70488 7/1/2004 N70490 7/1/2004 N70491 7/1/2004 N70492 7/1/2004 N70496 7/1/2004 N70498 7/1/2004 N70540 7/1/2004 N70542 7/1/2004 N70543 7/1/2004 N70544 7/1/2004 N70545 7/1/2004 N70546 7/1/2004 N70547 7/1/2004 N70548 7/1/2004 N70549 7/1/2004 N70551 7/1/2004 N70552 7/1/2004 N70553 7/1/2004 N70554 1/1/2007 N

Page 71 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range70555 1/1/2007 N71250 7/1/2004 N71260 7/1/2004 N71270 7/1/2004 N71275 7/1/2004 N71550 7/1/2004 N71551 7/1/2004 N71552 7/1/2004 N71555 7/1/2004 N72125 7/1/2004 N72126 7/1/2004 N72127 7/1/2004 N72128 7/1/2004 N72129 7/1/2004 N72130 7/1/2004 N72131 7/1/2004 N72132 7/1/2004 N72133 7/1/2004 N72141 7/1/2004 N72142 7/1/2004 N72146 7/1/2004 N72147 7/1/2004 N72148 7/1/2004 N72149 7/1/2004 N72156 7/1/2004 N72157 7/1/2004 N72158 7/1/2004 N72159 7/1/2004 N72191 7/1/2004 N72192 7/1/2004 N72193 7/1/2004 N72194 7/1/2004 N72195 7/1/2004 N72196 7/1/2004 N72197 7/1/2004 N72198 7/1/2004 N72200 7/1/2004 N72202 7/1/2004 N72240 7/1/2004 N72255 7/1/2004 N72265 7/1/2004 N72270 7/1/2004 N72275 7/1/2004 N73040 7/1/2004 N73050 7/1/2004 N73085 7/1/2004 N73115 7/1/2004 N73200 7/1/2004 N73201 7/1/2004 N73202 7/1/2004 N73206 7/1/2004 N73218 7/1/2004 N73219 7/1/2004 N73220 7/1/2004 N

Page 72 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range73221 7/1/2004 N73222 7/1/2004 N73223 7/1/2004 N73225 7/1/2004 N73525 7/1/2004 N73580 7/1/2004 N73700 7/1/2004 N73701 7/1/2004 N73702 7/1/2004 N73706 7/1/2004 N73718 7/1/2004 N73719 7/1/2004 N73720 7/1/2004 N73721 7/1/2004 N73722 7/1/2004 N73723 7/1/2004 N73725 7/1/2004 N74150 7/1/2004 N74160 7/1/2004 N74170 7/1/2004 N74174 1/1/2012 N74175 7/1/2004 N74176 1/1/2011 N74177 1/1/2011 N74178 1/1/2011 N74181 7/1/2004 N74182 7/1/2004 N74183 7/1/2004 N74185 7/1/2004 N74190 7/1/2004 N74235 7/1/2004 N74261 1/1/2011 N74262 1/1/2011 N74290 7/1/2004 N74300 7/1/2004 N74328 7/1/2004 N74329 7/1/2004 N74330 7/1/2004 N74340 7/1/2004 N74355 7/1/2004 N74360 7/1/2004 N74363 7/1/2004 N74400 7/1/2004 N74410 7/1/2004 N74415 7/1/2004 N74420 7/1/2004 N74425 7/1/2004 N74430 7/1/2004 N74440 7/1/2004 N74445 7/1/2004 N74450 7/1/2004 N74455 7/1/2004 N74470 7/1/2004 N74485 7/1/2004 N

Page 73 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range74710 7/1/2004 Y 10 through 55 years74712 1/1/2016 Y 12 through 55 years74713 1/1/2016 Y 12 through 55 years74740 7/1/2004 N74742 7/1/2004 N74775 7/1/2004 N75557 1/1/2008 N75559 1/1/2008 N75561 1/1/2008 N75563 1/1/2008 N75571 1/1/2010 Y 0 through 20 years75572 1/1/2010 Y 0 through 20 years75573 1/1/2010 Y 0 through 20 years75574 1/1/2010 Y 0 through 20 years75600 7/1/2004 N75605 7/1/2004 N75625 7/1/2004 N75630 7/1/2004 N75635 7/1/2004 N75662 7/1/2004 N75705 7/1/2004 N75710 7/1/2004 N75716 7/1/2004 N75726 7/1/2004 N75731 7/1/2004 N75733 7/1/2004 N75736 7/1/2004 N75741 7/1/2004 N75743 7/1/2004 N75746 7/1/2004 N75756 7/1/2004 N75774 1/1/2006 N75801 7/1/2004 N75803 7/1/2004 N75805 7/1/2004 N75807 7/1/2004 N75809 7/1/2004 N75810 7/1/2004 N75820 7/1/2004 N75822 7/1/2004 N75825 7/1/2004 N75827 7/1/2004 N75831 7/1/2004 N75833 7/1/2004 N75840 7/1/2004 N75842 7/1/2004 N75860 7/1/2004 N75870 7/1/2004 N75872 7/1/2004 N75880 7/1/2004 N75885 7/1/2004 N75887 7/1/2004 N75889 7/1/2004 N75891 7/1/2004 N

Page 74 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range75894 7/1/2004 N75898 7/1/2004 N75901 7/1/2004 N75902 7/1/2004 N75970 7/1/2004 N75984 7/1/2004 N75989 7/1/2004 N76376 1/1/2006 N76377 1/1/2006 N76380 7/1/2004 N76390 1/1/2006 N76391 1/1/2019 N76496 7/1/2004 N76497 7/1/2004 N76498 7/1/2004 N76506 7/1/2004 N76511 1/1/2005 N76512 1/1/2005 N76513 7/1/2004 N76514 7/1/2004 N76516 7/1/2004 N76519 7/1/2004 N76529 7/1/2004 N76536 7/1/2004 N76604 7/1/2004 N76641 1/1/2015 N76642 1/1/2015 N76700 7/1/2004 N76705 7/1/2004 N76706 1/1/2017 N76770 7/1/2004 N76775 7/1/2004 N76776 1/1/2007 N76800 7/1/2004 N76801 7/1/2004 Y 10 through 60 years76802 1/1/2006 Y 10 through 60 years76805 7/1/2004 Y 10 through 60 years76810 1/1/2006 Y 10 through 60 years76811 7/1/2004 Y 10 through 60 years76812 1/1/2006 Y 10 through 60 years76813 1/1/2007 N76814 1/1/2007 N76815 7/1/2004 Y 10 through 60 years76816 7/1/2004 Y 10 through 60 years76817 7/1/2004 Y 10 through 60 years76818 7/1/2004 Y 12 through 55 years76819 7/1/2004 Y 12 through 55 years76820 1/1/2005 Y 10 through 60 years76821 1/1/2005 Y 10 through 60 years76825 7/1/2004 Y 12 through 55 years76826 7/1/2004 Y 12 through 55 years76827 7/1/2004 Y 10 through 60 years76828 7/1/2004 Y 12 through 55 years76830 7/1/2004 N

Page 75 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range76831 7/1/2004 N76856 7/1/2004 N76857 7/1/2004 N76870 7/1/2004 N76872 7/1/2004 N76873 7/1/2004 N76881 1/1/2011 N76882 1/1/2011 N76885 7/1/2004 Y 0 through 12 months76886 7/1/2004 Y 0 through 1 year76930 7/1/2004 N76932 7/1/2004 N76936 7/1/2004 N76937 7/1/2004 N76940 7/1/2004 N76941 7/1/2004 Y 12 through 55 years76942 7/1/2004 N76945 7/1/2004 Y 12 through 55 years76946 7/1/2004 N76965 7/1/2004 N76970 7/1/2004 N76975 7/1/2004 N76977 7/1/2004 N76978 1/1/2019 N76979 1/1/2019 N76981 1/1/2019 N76982 1/1/2019 N76983 1/1/2019 N76998 1/1/2007 N77011 1/1/2007 N77013 1/1/2007 N77014 1/1/2007 N77022 1/1/2007 N77046 1/1/2019 N77047 1/1/2019 N77048 1/1/2019 N77049 1/1/2019 N77078 1/1/2007 N77080 1/1/2007 N77081 1/1/2007 N77084 1/1/2007 N77085 1/1/2015 N77086 1/1/2015 N77371 1/1/2007 N77372 1/1/2007 N77373 1/1/2007 N77385 1/1/2015 N77386 1/1/2015 N77387 1/1/2015 N77401 7/1/2004 N77402 7/1/2004 N77407 7/1/2004 N77412 7/1/2004 N77424 1/1/2012 N

Page 76 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range77425 1/1/2012 N77469 1/1/2012 N77600 7/1/2004 N77605 7/1/2004 N77610 7/1/2004 N77615 7/1/2004 N77620 7/1/2004 N77750 7/1/2004 N77761 7/1/2004 N77762 7/1/2004 N77763 7/1/2004 N77767 1/1/2016 N77768 1/1/2016 N77770 1/1/2016 N77771 1/1/2016 N77772 1/1/2016 N77778 7/1/2004 N77789 7/1/2004 N78012 1/1/2013 N78013 1/1/2013 N78014 1/1/2013 N78015 7/1/2004 N78016 7/1/2004 N78018 7/1/2004 N78020 1/1/2006 N78070 7/1/2004 N78071 1/1/2013 N78072 1/1/2012 N78075 7/1/2004 N78099 7/1/2004 N78102 7/1/2004 N78103 7/1/2004 N78104 7/1/2004 N78110 7/1/2004 N78111 7/1/2004 N78120 7/1/2004 N78121 7/1/2004 N78122 7/1/2004 N78130 7/1/2004 N78135 7/1/2004 N78140 7/1/2004 N78185 7/1/2004 N78191 7/1/2004 N78195 7/1/2004 N78199 7/1/2004 N78201 7/1/2004 N78202 7/1/2004 N78205 7/1/2004 N78206 7/1/2004 N78215 7/1/2004 N78216 7/1/2004 N78226 1/1/2012 N78227 1/1/2012 N78230 7/1/2004 N

Page 77 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range78231 7/1/2004 N78232 7/1/2004 N78258 7/1/2004 N78261 7/1/2004 N78262 7/1/2004 N78264 7/1/2004 N78265 1/1/2016 N78266 1/1/2016 N78267 7/1/2004 N78268 1/1/2006 N78278 7/1/2004 N78282 7/1/2004 N78290 7/1/2004 N78291 7/1/2004 N78299 7/1/2004 N78300 7/1/2004 N78305 7/1/2004 N78306 7/1/2004 N78315 7/1/2004 N78320 7/1/2004 N78350 7/1/2004 N78351 7/1/2004 N78399 7/1/2004 N78414 7/1/2004 N78428 7/1/2004 N78445 7/1/2004 N78451 1/1/2010 N78452 1/1/2010 N78453 1/1/2010 N78454 1/1/2010 N78456 7/1/2004 N78457 7/1/2004 N78458 7/1/2004 N78459 7/1/2004 N78466 7/1/2004 N78468 7/1/2004 N78469 7/1/2004 N78472 7/1/2004 N78473 7/1/2004 N78481 7/1/2004 N78483 7/1/2004 N78491 7/1/2004 N78492 7/1/2004 N78494 7/1/2004 N78496 1/1/2006 N78499 7/1/2004 N78580 7/1/2004 N78582 1/1/2012 N78591 7/1/2004 N78599 7/1/2004 N78600 7/1/2004 N78601 7/1/2004 N78605 7/1/2004 N78606 7/1/2004 N

Page 78 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range78607 7/1/2004 N78608 7/1/2004 N78609 7/1/2004 N78610 7/1/2004 N78630 7/1/2004 N78635 7/1/2004 N78645 7/1/2004 N78647 7/1/2004 N78650 7/1/2004 N78660 7/1/2004 N78699 7/1/2004 N78700 7/1/2004 N78701 7/1/2004 N78707 7/1/2004 N78708 7/1/2004 N78709 7/1/2004 N78710 7/1/2004 N78725 7/1/2004 N78730 7/1/2004 N78740 7/1/2004 N78761 7/1/2004 N78799 7/1/2004 N78800 7/1/2004 N78801 7/1/2004 N78802 7/1/2004 N78803 7/1/2004 N78804 7/1/2004 N78805 7/1/2004 N78806 7/1/2004 N78807 7/1/2004 N78811 1/1/2005 N78812 1/1/2005 N78813 1/1/2005 N78814 1/1/2005 N78815 1/1/2005 N78816 1/1/2005 N78999 7/1/2004 N79005 1/1/2005 N79101 1/1/2005 N79200 1/1/2005 N79300 7/1/2004 N79403 7/1/2004 N79440 7/1/2004 N79445 1/1/2005 N79999 7/1/2004 N86950 7/1/2004 N90870 7/1/2004 N90935 7/1/2004 N90937 7/1/2004 N90940 7/1/2004 N90945 7/1/2004 N90947 7/1/2004 N90997 7/1/2004 N90999 7/1/2004 N

Page 79 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range91010 7/1/2004 N91020 7/1/2004 N91030 7/1/2004 N91034 1/1/2005 N91035 1/1/2005 N91037 1/1/2005 N91038 1/1/2005 N91040 1/1/2005 N91065 7/1/2004 N91110 7/1/2004 N91111 1/1/2007 N91112 1/1/2013 N91120 1/1/2005 N91122 7/1/2004 N91132 7/1/2004 N91133 7/1/2004 N92018 7/1/2004 N92019 7/1/2004 N92265 7/1/2004 N92502 7/1/2004 N92511 1/1/2006 N92516 7/1/2004 N92520 7/1/2004 N92583 1/1/2006 N92584 7/1/2004 N92585 1/1/2006 N92586 1/1/2006 N92587 1/1/2006 N92588 1/1/2006 N92606 7/1/2004 N92611 7/1/2004 N92612 7/1/2004 N92614 7/1/2004 N92616 7/1/2004 N92620 1/1/2005 N92625 1/1/2005 N92700 7/1/2004 N92920 1/1/2013 N92921 1/1/2013 N92928 1/1/2013 N92929 1/1/2013 N92924 1/1/2013 N92925 1/1/2013 N92933 1/1/2013 N92934 1/1/2013 N92937 1/1/2013 N92938 1/1/2013 N92941 1/1/2013 N92943 1/1/2013 N92944 1/1/2013 N92953 7/1/2004 N92960 7/1/2004 N92961 7/1/2004 N92973 1/1/2006 N

Page 80 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range92974 1/1/2006 N92977 7/1/2004 N92978 1/1/2006 N92979 1/1/2006 N92981 1/1/2006 N92982 7/1/2004 N92986 7/1/2004 N92987 7/1/2004 N92990 7/1/2004 N92997 7/1/2004 N92998 1/1/2006 N93015 7/1/2004 N93017 7/1/2004 N93025 1/1/2006 N93224 7/1/2004 N93225 7/1/2004 N93226 7/1/2004 N93270 7/1/2004 N93271 7/1/2004 N93303 7/1/2004 N93304 7/1/2004 N93306 1/1/2009 N93307 7/1/2004 N93308 7/1/2004 N93312 7/1/2004 N93313 7/1/2004 N93315 7/1/2004 N93316 7/1/2004 N93318 7/1/2004 N93320 1/1/2006 N93321 1/1/2006 N93325 1/1/2006 N93350 7/1/2004 N93351 1/1/2009 N93355 1/1/2015 N93451 1/1/2011 N93452 1/1/2011 N93453 1/1/2011 N93454 1/1/2011 N93455 1/1/2011 N93456 1/1/2011 N93457 1/1/2011 N93458 1/1/2011 N93459 1/1/2011 N93460 1/1/2011 N93461 1/1/2011 N93462 1/1/2011 N93503 7/1/2004 N93505 7/1/2004 N93530 7/1/2004 N93531 7/1/2004 N93532 7/1/2004 N93533 7/1/2004 N93561 7/1/2004 N

Page 81 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range93562 7/1/2004 N93563 1/1/2011 N93564 1/1/2011 N93565 1/1/2011 N93566 1/1/2011 N93567 1/1/2011 N93568 1/1/2011 N93571 7/1/2004 N93572 1/1/2006 N93580 7/1/2004 N93581 7/1/2004 N93590 1/1/2017 N93591 1/1/2017 N93592 1/1/2017 N93582 1/1/2014 N93600 7/1/2004 N93602 7/1/2004 N93603 7/1/2004 N93609 7/1/2004 N93610 7/1/2004 N93612 7/1/2004 N93613 1/1/2006 N93615 7/1/2004 N93616 7/1/2004 N93618 7/1/2004 N93619 7/1/2004 N93620 7/1/2004 N93621 1/1/2006 N93622 1/1/2006 N93623 1/1/2006 N93624 7/1/2004 N93631 7/1/2004 N93640 7/1/2004 N93641 7/1/2004 N93642 7/1/2004 N93644 1/1/2015 N93650 7/1/2004 N93653 1/1/2013 N93654 1/1/2013 N93655 1/1/2013 N93656 1/1/2013 N93657 1/1/2013 N93660 7/1/2004 N93662 1/1/2006 N93701 7/1/2004 N93702 1/1/2015 N93745 1/1/2005 N93784 7/1/2004 N93786 1/1/2006 N93799 7/1/2004 N93880 7/1/2004 N93882 7/1/2004 N93886 7/1/2004 N93888 7/1/2004 N

Page 82 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range93890 1/1/2005 N93892 1/1/2005 N93893 1/1/2005 N93922 1/1/2006 N93923 7/1/2004 N93924 7/1/2004 N93925 1/1/2006 N93926 1/1/2006 N93930 1/1/2006 N93931 1/1/2006 N93970 7/1/2004 N93971 7/1/2004 N93975 7/1/2004 N93976 7/1/2004 N93978 7/1/2004 N93979 7/1/2004 N93980 7/1/2004 N93981 1/1/2006 N93990 1/1/2006 N93998 1/1/2012 N94452 1/1/2006 N94453 1/1/2006 N94617 1/1/2018 N94618 1/1/2018 N94620 1/1/2006 N94621 7/1/2004 N94662 1/1/2006 N94680 7/1/2004 N94681 7/1/2004 N94690 7/1/2004 N94729 1/1/2012 N94750 7/1/2004 N94770 7/1/2004 N94772 7/1/2004 N95070 7/1/2004 N95071 7/1/2004 N95180 7/1/2004 N95782 1/1/2013 Y 0 through 5 years95783 1/1/2013 Y 0 through 5 years95805 7/1/2004 N95806 7/1/2004 N95807 7/1/2004 N95808 7/1/2004 N95810 7/1/2004 Y 6 through 99 years95811 7/1/2004 Y 6 through 99 years95812 7/1/2004 N95813 7/1/2004 N95816 7/1/2004 N95819 7/1/2004 N95822 7/1/2004 N95827 7/1/2004 N95857 1/1/2006 N95860 7/1/2004 N95861 7/1/2004 N

Page 83 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range95863 7/1/2004 N95864 7/1/2004 N95865 1/1/2006 N95866 1/1/2006 N95867 7/1/2004 N95868 7/1/2004 N95869 7/1/2004 N95870 7/1/2004 N95872 7/1/2004 N95873 1/1/2006 N95874 1/1/2006 N95875 7/1/2004 N95905 1/1/2010 N95907 1/1/2013 N95908 1/1/2013 N95909 1/1/2013 N95910 1/1/2013 N95911 1/1/2013 N95912 1/1/2013 N95913 1/1/2013 N95921 7/1/2004 N95922 7/1/2004 N95923 7/1/2004 N95924 1/1/2013 N95925 7/1/2004 N95926 7/1/2004 N95927 7/1/2004 N95928 1/1/2005 N95929 1/1/2005 N95930 5/1/2005 N95933 7/1/2004 N95937 7/1/2004 N95938 1/1/2012 N95939 1/1/2012 N95943 1/1/2013 N95950 7/1/2004 N95951 7/1/2004 N95953 7/1/2004 N95954 7/1/2004 N95955 7/1/2004 N95956 7/1/2004 N95957 7/1/2004 N95958 7/1/2004 N95961 7/1/2004 N95965 7/1/2004 N95966 7/1/2004 N95967 1/1/2006 N95999 7/1/2004 N96000 7/1/2004 N96001 7/1/2004 N96002 7/1/2004 N96003 7/1/2004 N96360 1/1/2009 N96361 1/1/2009 N

Page 84 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age Range96365 1/1/2009 N96366 1/1/2009 N96367 1/1/2009 N96368 1/1/2009 N96369 1/1/2009 N96370 1/1/2009 N96371 1/1/2009 N96373 1/1/2009 N96374 1/1/2009 N96375 1/1/2009 N96376 1/1/2009 N96379 1/1/2009 N96567 7/1/2004 N96570 1/1/2006 N96571 1/1/2006 N96573 1/1/2018 N96574 1/1/2018 N96999 7/1/2004 N97597 1/1/2005 N97598 1/1/2005 N97602 7/1/2004 N97605 1/1/2005 N97606 1/1/2005 N0016T 7/1/2004 N0042T 7/1/2004 N0073T 1/1/2005 N0075T 1/1/2006 N0076T 1/1/2006 N0095T 1/1/2006 N0101T 1/1/2006 N0102T 1/1/2006 N0245T 1/1/2011 N0246T 1/1/2011 NC9600 1/1/2013 NC9601 1/1/2013 NC9602 1/1/2013 NC9603 1/1/2013 NC9604 1/1/2013 NC9605 1/1/2013 NC9606 1/1/2013 NC9607 1/1/2013 ND0120 1/1/2005 Y 0 through 20 yearsD0140 1/1/2005 ND0150 1/1/2005 ND0210 1/1/2005 ND0220 1/1/2005 ND0230 1/1/2005 ND0270 1/1/2005 ND0272 1/1/2005 ND0274 1/1/2005 ND0277 1/1/2005 ND0330 1/1/2005 ND1120 1/1/2005 Y 0 through 20 yearsD1351 1/1/2005 Y 0 through 20 years

Page 85 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age RangeD1510 1/1/2005 Y 0 through 20 yearsD1515 1/1/2005 Y 0 through 20 yearsD1525 1/1/2005 Y 0 through 20 yearsD1550 1/1/2005 Y 0 through 20 yearsD2140 1/1/2005 ND2150 1/1/2005 ND2160 1/1/2005 ND2161 1/1/2005 ND2330 1/1/2005 ND2331 1/1/2005 ND2332 1/1/2005 ND2335 1/1/2005 ND2391 1/1/2005 ND2392 1/1/2005 ND2393 1/1/2005 ND2394 1/1/2005 ND2740 1/1/2005 ND2750 1/1/2005 ND2751 1/1/2005 ND2752 1/1/2005 ND2790 1/1/2005 ND2791 1/1/2005 ND2792 1/1/2005 ND2910 1/1/2005 ND2915 1/1/2005 ND2920 1/1/2005 ND2930 1/1/2005 Y 0 through 20 yearsD2931 1/1/2005 ND2932 1/1/2005 ND2940 1/1/2005 ND2951 1/1/2005 ND2954 1/1/2005 ND3220 1/1/2005 Y 0 through 20 yearsD3310 1/1/2005 ND3320 1/1/2005 Y 0 through 20 yearsD3330 1/1/2005 Y 0 through 20 yearsD3351 1/1/2005 Y 0 through 20 yearsD3352 1/1/2005 Y 0 through 20 yearsD3353 1/1/2005 Y 0 through 20 yearsD3410 1/1/2005 Y 0 through 20 yearsD4210 1/1/2005 Y 0 through 20 yearsD4211 1/1/2005 Y 0 through 20 yearsD4240 1/1/2005 Y 0 through 20 yearsD4241 1/1/2005 Y 0 through 20 yearsD4260 1/1/2005 Y 0 through 20 yearsD4261 1/1/2005 Y 0 through 20 yearsD4263 1/1/2005 Y 0 through 20 yearsD4264 1/1/2005 Y 0 through 20 yearsD4270 1/1/2005 Y 0 through 20 yearsD4271 1/1/2005 Y 0 through 20 yearsD4272 1/1/2005 Y 0 through 20 yearsD4273 1/1/2005 Y 0 through 20 yearsD4274 1/1/2005 Y 0 through 20 yearsD4320 1/1/2005 Y 0 through 20 years

Page 86 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age RangeD4321 1/1/2005 Y 0 through 20 yearsD4341 1/1/2005 Y 0 through 20 yearsD4342 1/1/2005 Y 0 through 20 yearsD4910 1/1/2005 Y 0 through 20 yearsD5110 1/1/2005 ND5120 1/1/2005 ND5130 1/1/2005 ND5140 1/1/2005 ND5211 1/1/2005 Y 0 through 20 yearsD5212 1/1/2005 Y 0 through 20 yearsD5213 1/1/2005 Y 0 through 20 yearsD5214 1/1/2005 Y 0 through 20 yearsD5510 1/1/2005 ND5520 1/1/2005 ND5610 1/1/2005 ND5620 1/1/2005 ND5630 1/1/2005 ND5640 1/1/2005 ND5650 1/1/2005 ND5730 1/1/2005 ND5731 1/1/2005 ND5740 1/1/2005 ND5741 1/1/2005 ND5750 1/1/2005 ND5751 1/1/2005 ND5760 1/1/2005 ND5761 1/1/2005 ND5911 1/1/2005 ND5912 1/1/2005 ND5913 1/1/2005 ND5914 1/1/2005 ND5915 1/1/2005 ND5916 1/1/2005 ND5919 1/1/2005 ND5922 1/1/2005 ND5923 1/1/2005 ND5924 1/1/2005 ND5925 1/1/2005 ND5926 1/1/2005 ND5927 1/1/2005 ND5928 1/1/2005 ND5929 1/1/2005 ND5931 1/1/2005 ND5932 1/1/2005 ND5933 1/1/2005 ND5934 1/1/2005 ND5935 1/1/2005 ND5936 1/1/2005 ND5937 1/1/2005 ND5951 1/1/2005 ND5952 1/1/2005 Y 0 through 20 yearsD5953 1/1/2005 ND5954 1/1/2005 ND5955 1/1/2005 N

Page 87 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age RangeD5958 1/1/2005 ND5959 1/1/2005 ND5960 1/1/2005 ND5982 1/1/2005 ND5983 1/1/2005 ND5984 1/1/2005 ND5985 1/1/2005 ND5986 1/1/2005 ND5987 1/1/2005 ND5988 1/1/2005 ND5999 1/1/2005 ND6210 1/1/2005 Y 0 through 20 yearsD6211 1/1/2005 Y 0 through 20 yearsD6212 1/1/2005 Y 0 through 20 yearsD6240 1/1/2005 Y 0 through 20 yearsD6241 1/1/2005 Y 0 through 20 yearsD6242 1/1/2005 Y 0 through 20 yearsD6251 1/1/2005 Y 0 through 20 yearsD6721 1/1/2005 Y 0 through 20 yearsD6750 1/1/2005 Y 0 through 20 yearsD6751 1/1/2005 Y 0 through 20 yearsD6752 1/1/2005 Y 0 through 20 yearsD6790 1/1/2005 Y 0 through 20 yearsD6791 1/1/2005 Y 0 through 20 yearsD6792 1/1/2005 Y 0 through 20 yearsD6930 1/1/2005 ND6972 1/1/2005 Y 0 through 20 yearsD7140 1/1/2005 ND7210 1/1/2005 ND7220 1/1/2005 ND7230 1/1/2005 ND7240 1/1/2005 ND7250 1/1/2005 ND7280 1/1/2005 Y 0 through 20 yearsD7283 1/1/2005 Y 0 through 20 yearsD7310 1/1/2005 Y 0 through 20 yearsD7311 1/1/2005 Y 0 through 20 yearsD7320 1/1/2005 Y 0 through 20 yearsD7321 1/1/2005 Y 0 through 20 yearsD7450 1/1/2005 ND7451 1/1/2005 ND7460 1/1/2005 ND7461 1/1/2005 ND7510 1/1/2005 ND7511 1/1/2005 ND7610 1/1/2005 ND7620 1/1/2005 ND7630 1/1/2005 ND7640 1/1/2005 ND7710 1/1/2005 ND7720 1/1/2005 ND7730 1/1/2005 ND7740 1/1/2005 ND7810 1/1/2005 N

Page 88 of 89

Ambulatory Procedures Listing (APL)Sorted in Code Order

Illinois Department of Healthcare and Family ServicesEffective January 1, 2019

CPT/HCPCS Code APL Begin Date Age Limit (Y/N) Age RangeD7820 1/1/2005 ND7960 1/1/2005 Y 0 through 20 yearsD7963 1/1/2005 Y 0 through 20 yearsD8080 1/1/2005 Y 0 through 20 yearsD8660 1/1/2005 Y 0 through 20 yearsD8670 1/1/2005 Y 0 through 20 yearsD8999 1/1/2005 Y 0 through 20 yearsD9110 1/1/2005 ND9230 1/1/2005 ND9310 1/1/2005 ND9610 1/1/2005 ND9630 1/1/2005 ND9999 1/1/2005 NG0104 10/1/2005 NG0105 10/1/2005 NG0121 10/1/2005 NG0219 7/1/2004 NG0277 1/1/2015 NG0297 7/1/2004 NG0300 7/1/2004 NG0339 1/1/2006 NG0340 1/1/2006 NG0365 1/1/2005 NS2070 7/1/2004 NS2075 1/1/2008 NS2118 1/1/2009 NS2225 7/1/2004 N

For service dates billed through 12/31/16, Revenue Code 0762 must be billed with one of the following HCPCS codes: 99218, 99219, 99220, 99234, 99235 or 99236. Effective 1/1/17, for service dates 4/1/16 through 12/31/16, providers have the option to bill the E & M codes with G0378, or may bill G0379 with G0378. For service dates beginning 1/1/17, all observation claims received by the Department must be coded with G0379 and G0378. Providers must continue to identify two revenue lines for observation, with the first Revenue Code 0762 billed with G0379, and a second Revenue Code 0762 billed with G0378. These coding requirements also apply to claims with Medicare Part B as the primary payer (Medicare crossovers).

Psychiatric Clinic Type B intensive outpatient program (IOP) claims must be coded with Revenue code 0913. Partial hospitalization program (PHP) claims must be coded with Revenue Code 0912.

Psychiatric Clinic ServicesPsychiatric Clinic Type A services must be billed with one of the following HCPCS Codes: 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90870, 90875, 90876, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, and 99215.

Psychiatric Clinic Type B services must be billed with the following HCPCS Code: S9480

Emergency Room ServicesRevenue Code 0450 must be billed with one of the following HCPCS Codes: 99284, 99285, 99291, G0383, or G0384Revenue Code 0456 must be billed with one of the following HCPCS Codes: 99282, 99283, G0381, or G0382Revenue Code 0451 must be billed with the following HCPCS Code: 99281 or G0380

Observation Services

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