Department of Health

Professional Services Fee Schedule

Updated July 2018

Maryland Medical Assistance

Professional Services Fee Schedule July 2018

Maryland Medical Assistance FS-2

Overview

Professional Services Fee Schedule – July 2018

Introduction This Fee Schedule includes the current CPT codes and their

maximum reimbursement that the Physicians’ Services program

pays for each procedure. To clarify and assist providers in using

and navigating this Fee Schedule, it also contains information on

the limitations on its use, abbreviations in the schedule, and

electronic format information. All rates are based upon the

Medicare Part-B Fee Schedule.

In This Chapter This chapter contains:

TOPIC PAGE

Limitations of the Fee Schedule FS-2

Abbreviations Used in the Fee Schedule FS-3

Electronic Formats FS-5

Special Note FS-5 Fee Schedule FS-7

HCPCS Level II Fee Schedule

Fee Schedule

FS-98

Limitations of the Fee Schedule

All reimbursement rates and additional documentation

requirements only apply to professional services when recipients

have coverage under fee-for-service. Recipients with Managed

Care Organization (MCO) coverage through the HealthChoice

program may have different requirements.

This fee schedule does not contain reimbursement rates for all

of the HCPCS Level-II codes (beginning with Alpha characters A

through W) outside of the injectables that pertain to professional

services, digital mammography codes (G0202, G0204, and

G0206) and other replacement codes (G0453 and G0455).

Professional Services Fee Schedule July 2018

Maryland Medical Assistance FS-3

J- codes are now published in this fee schedule. All

providers must bill J-codes at their exact acquisition

costs, NOT usual and customary charges or average

wholesale price (AWP).

Limitations (cont.)

There are separate fee schedules for Durable Medical Equipment

(DME), Durable Medical Supplies (DMS), and Oxygen providers,

as well as laboratory and pathology codes in the 80000 series.

These schedules are available online at:

https://mmcp.health.maryland.gov/Pages/Provider-

Information.aspx.

This fee schedule does not contain any CPT Category II

(Performance Measurement) or CPT Category III (Emerging

Technology & Procedures) codes. The Program does not

reimburse providers for these procedures.

Abbreviations Used in the Fee Schedule

The following abbreviations are used in the fee schedule:

Abbreviation Details

NFAC Non-Facility Fee. The Non-Facility Fee is the

fee schedule amount for services rendered in an

office, home, or school setting. For many

procedures, the Non-Facility and Facility rates are

identical. Certain procedures may have higher

non-facility rates compared to facility rates to

accommodate overhead and indirect expenses

providers incur by operating their own facility.

FAC Facility Fee. The Facility Fee is the fee schedule

amount for services rendered in a hospital

(inpatient or outpatient), psychiatric hospital

(inpatient or outpatient), nursing facility or skilled

nursing facility.

Professional Services Fee Schedule July 2018

Maryland Medical Assistance FS-4

26 Modifier 26. The Modifier -26 Fee is the amount for only the professional component

of a procedure, where applicable.

TC Modifier TC. The Modifier -TC Fee is the

amount for only the technical component of a

procedure, where applicable.

NOTE The NOTE column is used to designate whether

a code requires additional documentation, and

may contain one of four abbreviations, listed

below. The documentation for each of these

forms may be found at:

https://mmcp.health.maryland.gov/Pages/Provid

er-Information.aspx.

A Abortion Form Required. Certain services

require the Certification for Abortion Form

(DHMH 521) to be completed and kept in the

patient’s Medical Record.

H Hysterectomy Form Required. Certain services

require the Document for Hysterectomy Form

(DHMH 2990) to be completed and kept in the

patient’s Medical Record.

S Sterilization Form Required. Certain services

require the Sterilization Consent Form (DHMH

2989) to be completed and kept in the

patient’s Medical Record.

P Prior Authorization Required. Certain services

require prior authorization. Requests for

preauthorization are made in writing and must

document that the services are medically

necessary.

INVOICE /

REPORT

Rates with INVOICE / REPORT require

additional documentation in order to be

Abbreviations (cont.)

Maryland Medical Assistance FS-5

Professional Services Fee Schedule July 2018

priced. Documentation may include (but is not

limited to) medical notes, surgery notes, or

invoices from a manufacturer or wholesaler.

N.C.

Rates with N.C. are considered non-covered

services by the Program

N/A Rates with N/A are not considered an appropriate service for the designated Place of Service.

Electronic Formats The fee schedule is available in both PDF and Excel (.xls) versions

for your convenience. The reimbursement rates between these

two versions should be identical; if there are discrepancies,

please use the PDF version as the official rate.

To conveniently locate a specific code, please use the “Find”

search functions on your computer (On Windows: CTRL + F. On

Mac: CMD + F).

Special Note Please use G0453 in place of 95941, and G0455 in place of

44705. The rates for both of these replacement codes in this Fee

Schedule.

Unlisted/Unclassified procedure codes are listed in this Fee

Schedule; however, these codes must be manually priced.

Therefore, all claims using an unlisted/unclassified code must

include legible surgical notes or other medical record

documentation to enable a medical reviewer to arrive at a value

for the procedure and to determine whether the service will be

covered by the Program.

When billing for unlisted procedures, include:

● A description of the service provided as well the

Maryland Medical Assistance FS-6

Professional Services Fee Schedule July 2018

reason the procedure was medically necessary;

● A comparable CPT code;

● If there is a third party payor (Medicare, CareFirst,

etc.), the explanation of Benefits (EOB) from

Medicare or third party payer must be attached; and

● In some cases additional information may be

required.

Failure to provide the aforementioned information WILL result

in a denial of the claim.

Maryland Medical Assistance FS-7

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

00100 1.1486 1.1500

00102 1.1486 1.1500

00103 1.1486 1.1500

00104 1.1486 1.1500

00120 1.1486 1.1500

00124 1.1486 1.1500

00126 1.1486 1.1500

00140 1.1486 1.1500

00142 1.1486 1.1500

00144 1.1486 1.1500

00145 1.1486 1.1500

00147 1.1486 1.1500

00148 1.1486 1.1500

00160 1.1486 1.1500

00162 1.1486 1.1500

00164 1.1486 1.1500

00170 1.5546 1.5500

00172 1.1486 1.1500

00174 1.1486 1.1500

00176 1.1486 1.1500

00190 1.1486 1.1500

00192 1.1486 1.1500

00210 1.1486 1.1500

00211 1.1486 1.1500

00212 1.1486 1.1500

00214 1.1486 1.1500

00215 1.1486 1.1500

00216 1.1486 1.1500

00218 1.1486 1.1500

00220 1.1486 1.1500

00222 1.1486 1.1500

00300 1.1486 1.1500

00320 1.1486 1.1500

00322 1.1486 1.1500

00326 1.1486 1.1500

00350 1.1486 1.1500

00352 1.1486 1.1500

00400 1.1486 1.1500

00402 1.1486 1.1500

00404 1.1486 1.1500

00406 1.1486 1.1500

CODE NOTE NFAC FAC 26 TC

00410 1.1486 1.1500

00450 1.1486 1.1500

00454 1.1486 1.1500

00470 1.1486 1.1500

00472 1.1486 1.1500

00474 1.1486 1.1500

00500 1.1486 1.1500

00520 1.1486 1.1500

00522 1.1486 1.1500

00524 1.1486 1.1500

00528 1.1486 1.1500

00529 1.1486 1.1500

00530 1.1486 1.1500

00532 1.1486 1.1500

00534 1.1486 1.1500

00537 1.1486 1.1500

00539 1.1486 1.1500

00540 1.1486 1.1500

00541 1.1486 1.1500

00542 1.1486 1.1500

00546 1.1486 1.1500

00548 1.1486 1.1500

00550 1.1486 1.1500

00560 1.1486 1.1500

00561 1.1486 1.1500

00562 1.1486 1.1500

00563 1.1486 1.1500

00566 1.1486 1.1500

00567 1.1486 1.1500

00580 1.1486 1.1500

00600 1.1486 1.1500

00604 1.1486 1.1500

00620 1.1486 1.1500

00625 1.0940 1.0900

00626 1.0940 1.0900

00630 1.1486 1.1500

00632 1.1486 1.1500

00635 1.1486 1.1500

00640 1.1486 1.1500

00670 1.1486 1.1500

00700 1.1486 1.1500

Maryland Medical Assistance FS-8

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

00702 1.1486 1.1500

00730 1.1486 1.1500

00731 1.1486 1.1500

00732 1.1486 1.1500

00750 1.1486 1.1500

00752 1.1486 1.1500

00754 1.1486 1.1500

00756 1.1486 1.1500

00770 1.1486 1.1500

00790 1.1486 1.1500

00792 1.1486 1.1500

00794 1.1486 1.1500

00796 1.1486 1.1500

00797 1.1486 1.1500

00800 1.1486 1.1500

00802 P 1.1486 1.1500

00811 1.1486 1.1500

00812 1.1486 1.1500

00813 1.1486 1.1500

00820 1.1486 1.1500

00830 1.1486 1.1500

00832 1.1486 1.1500

00834 1.1486 1.1500

00836 1.1486 1.1500

00840 1.1486 1.1500

00842 1.1486 1.1500

00844 1.1486 1.1500

00846 H 1.1486 1.1500

00848 1.1486 1.1500

00851 S 1.1486 1.1500

00860 1.1486 1.1500

00862 1.1486 1.1500

00864 1.1486 1.1500

00865 1.1486 1.1500

00866 1.1486 1.1500

00868 1.1486 1.1500

00870 1.1486 1.1500

00872 1.1486 1.1500

00873 1.1486 1.1500

00880 1.1486 1.1500

00882 1.1486 1.1500

00902 1.1486 1.1500

00904 1.1486 1.1500

CODE NOTE NFAC FAC 26 TC

00906 1.1486 1.1500

00908 1.1486 1.1500

00910 1.1486 1.1500

00912 1.1486 1.1500

00914 1.1486 1.1500

00916 1.1486 1.1500

00918 1.1486 1.1500

00920 1.1486 1.1500

00921 S 1.1486 1.1500

00922 1.1486 1.1500

00924 1.1486 1.1500

00926 1.1486 1.1500

00928 1.1486 1.1500

00930 1.1486 1.1500

00932 1.1486 1.1500

00934 1.1486 1.1500

00936 1.1486 1.1500

00938 1.1486 1.1500

00940 1.1486 1.1500

00942 1.1486 1.1500

00944 H 1.1486 1.1500

00948 1.1486 1.1500

00950 1.1486 1.1500

00952 1.1486 1.1500

01112 1.1486 1.1500

01120 1.1486 1.1500

01130 1.1486 1.1500

01140 1.1486 1.1500

01150 1.1486 1.1500

01160 1.1486 1.1500

01170 1.1486 1.1500

01173 1.1486 1.1500

01200 1.1486 1.1500

01202 1.1486 1.1500

01210 1.1486 1.1500

01212 1.1486 1.1500

01214 1.1486 1.1500

01215 1.1486 1.1500

01220 1.1486 1.1500

01230 1.1486 1.1500

01232 1.1486 1.1500

01234 1.1486 1.1500

01250 1.1486 1.1500

Maryland Medical Assistance FS-9

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

01260 1.1486 1.1500

01270 1.1486 1.1500

01272 1.1486 1.1500

01274 1.1486 1.1500

01320 1.1486 1.1500

01340 1.1486 1.1500

01360 1.1486 1.1500

01380 1.1486 1.1500

01382 1.1486 1.1500

01390 1.1486 1.1500

01392 1.1486 1.1500

01400 1.1486 1.1500

01402 1.1486 1.1500

01404 1.1486 1.1500

01420 1.1486 1.1500

01430 1.1486 1.1500

01432 1.1486 1.1500

01440 1.1486 1.1500

01442 1.1486 1.1500

01444 1.1486 1.1500

01462 1.1486 1.1500

01464 1.1486 1.1500

01470 1.1486 1.1500

01472 1.1486 1.1500

01474 1.1486 1.1500

01480 1.1486 1.1500

01482 1.1486 1.1500

01484 1.1486 1.1500

01486 1.1486 1.1500

01490 1.1486 1.1500

01500 1.1486 1.1500

01502 1.1486 1.1500

01520 1.1486 1.1500

01522 1.1486 1.1500

01610 1.1486 1.1500

01620 1.1486 1.1500

01622 1.1486 1.1500

01630 1.1486 1.1500

01634 1.1486 1.1500

01636 1.1486 1.1500

01638 1.1486 1.1500

01650 1.1486 1.1500

01652 1.1486 1.1500

CODE NOTE NFAC FAC 26 TC

01654 1.1486 1.1500

01656 1.1486 1.1500

01670 1.1486 1.1500

01680 1.1486 1.1500

01710 1.1486 1.1500

01712 1.1486 1.1500

01714 1.1486 1.1500

01716 1.1486 1.1500

01730 1.1486 1.1500

01732 1.1486 1.1500

01740 1.1486 1.1500

01742 1.1486 1.1500

01744 1.1486 1.1500

01756 1.1486 1.1500

01758 1.1486 1.1500

01760 1.1486 1.1500

01770 1.1486 1.1500

01772 1.1486 1.1500

01780 1.1486 1.1500

01782 1.1486 1.1500

01810 1.1486 1.1500

01820 1.1486 1.1500

01829 1.1486 1.1500

01830 1.1486 1.1500

01832 1.1486 1.1500

01840 1.1486 1.1500

01842 1.1486 1.1500

01844 1.1486 1.1500

01850 1.1486 1.1500

01852 1.1486 1.1500

01860 1.1486 1.1500

01916 1.1486 1.1500

01920 1.1486 1.1500

01922 1.1486 1.1500

01924 1.1486 1.1500

01925 1.1486 1.1500

01926 1.1486 1.1500

01930 1.1486 1.1500

01931 1.1486 1.1500

01932 1.1486 1.1500

01933 1.1486 1.1500

01935 1.2943 1.2900

01936 1.2943 1.2900

Maryland Medical Assistance FS-10

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

01951 1.1486 1.1500

01952 1.1486 1.1500

01953 1.1486 1.1500

01958 1.2479 1.2500

01960 1.2479 1.2500

01961 1.2479 1.2500

01962 H 1.2479 1.2500

01963 H 1.2479 1.2500

01965 1.2479 1.2500

01966 A 1.2479 1.2500

01967 1.2479 1.2500

01968 1.2479 1.2500

01969 H 1.2479 1.2500

01990 1.1486 1.1500

01991 1.1486 1.1500

01992 1.1486 1.1500

01996 1.1486 1.1500

01999 REPORT REPORT REPORT

10021 103.10 55.22

10022 112.07 51.65

10030 649.73 129.95

10035 471.14 74.96

10036 410.56 37.77

10040 80.70 70.44

10060 93.07 77.39

10061 163.48 142.67

10080 143.14 82.13

10081 214.01 134.78

10120 121.33 82.29

10121 217.74 147.63

10140 129.70 94.07

10160 103.10 76.31

10180 196.99 143.41

11000 42.94 23.50

11001 16.93 11.90

11004 464.61 464.61

11005 630.91 630.91

11006 566.22 566.22

11008 221.87 221.87

11010 404.71 228.86

11011 429.49 240.82

11012 568.64 342.61

11042 92.58 48.98

CODE NOTE NFAC FAC 26 TC

11043 187.00 128.88

11044 252.62 223.59

11045 32.37 20.69

11046 58.28 44.88

11047 99.02 79.92

11055 37.89 16.96

11056 46.19 23.79

11057 51.64 31.24

11100 82.38 39.06

11101 25.95 19.96

11200 70.39 58.99

11201 14.98 13.27

11300 78.39 28.23

11301 96.21 42.91

11302 113.42 50.43

11303 125.12 59.57

11305 78.83 30.95

11306 97.77 41.34

11307 114.85 53.29

11308 120.02 58.17

11310 91.23 37.93

11311 88.24 52.33

11312 128.49 62.65

11313 148.79 80.39

11400 99.10 64.61

11401 118.83 83.20

11402 132.34 91.30

11403 153.02 118.25

11404 173.86 130.26

11406 250.13 197.98

11420 97.39 65.18

11421 124.49 88.01

11422 139.67 108.59

11423 160.34 125.56

11424 186.09 144.20

11426 265.45 220.14

11440 107.07 82.28

11441 133.57 104.79

11442 149.55 116.20

11443 178.19 142.57

11444 223.84 181.67

11446 310.38 260.50

11450 305.43 203.11

Maryland Medical Assistance FS-11

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

11451 388.63 261.24

11462 298.46 194.15

11463 393.50 262.39

11470 329.10 225.07

11471 407.63 280.25

11600 153.38 95.53

11601 182.48 119.49

11602 197.88 131.19

11603 226.00 157.30

11604 251.28 173.18

11606 359.18 257.14

11620 154.85 96.70

11621 183.64 120.36

11622 204.57 137.88

11623 239.60 170.33

11624 270.38 193.13

11626 325.14 236.51

11640 159.93 100.07

11641 189.77 125.36

11642 216.57 147.87

11643 254.86 185.03

11644 313.81 228.58

11646 409.79 317.42

11719 14.02 6.85

11720 25.40 12.49

11721 35.32 21.42

11730 82.95 43.75

11732 31.83 17.30

11740 39.31 25.91

11750 141.90 111.52

11755 105.34 61.42

11760 150.09 97.47

11762 220.54 148.03

11765 133.12 74.68

11770 221.36 148.40

11771 458.00 348.54

11772 554.97 462.62

11900 44.30 24.93

11901 55.61 38.79

11920 142.37 91.10

11921 161.06 107.22

11922 48.96 23.88

11950 61.91 42.53

CODE NOTE NFAC FAC 26 TC

11951 79.42 58.05

11952 102.40 74.38

11954 125.60 91.96

11960 762.45 762.45

11970 488.59 488.59

11971 375.55 255.26

11976 112.83 74.35

11980 75.47 57.79

11981 112.44 66.27

11982 127.45 80.42

11983 178.37 139.63

12001 88.44 43.48

12002 113.25 57.47

12004 132.79 71.87

12005 165.27 93.29

12006 205.54 114.92

12007 231.38 144.22

12011 113.41 73.52

12013 124.53 56.66

12014 131.12 73.06

12015 158.75 92.20

12016 216.91 125.70

12017 153.39 153.39

12018 173.49 173.49

12020 223.31 150.64

12021 128.91 109.81

12031 189.45 123.05

12032 242.02 156.80

12034 248.65 166.57

12035 303.67 192.53

12036 335.69 223.67

12037 383.95 263.97

12041 188.98 120.85

12042 230.25 161.27

12044 286.14 172.14

12045 319.16 216.26

12046 380.19 249.06

12047 437.22 296.70

12051 205.50 137.66

12052 234.13 164.01

12053 275.07 174.75

12054 286.60 178.01

12055 371.36 244.54

Maryland Medical Assistance FS-12

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

12056 389.23 273.24

12057 432.93 314.65

13100 266.77 165.58

13101 315.67 203.95

13102 96.75 59.70

13120 278.99 190.05

13121 340.34 219.93

13122 106.18 68.84

13131 307.08 201.05

13132 379.17 318.39

13133 142.17 105.69

13151 336.21 231.04

13152 403.24 298.96

13153 154.50 113.74

13160 642.93 642.93

14000 496.45 403.81

14001 640.28 527.72

14020 555.48 456.60

14021 694.32 577.47

14040 606.64 507.45

14041 751.90 628.44

14060 618.27 540.43

14061 809.18 680.92

14301 858.91 708.69

14302 177.77 177.77

14350 545.36 545.36

15002 277.03 182.12

15003 60.32 36.66

15004 318.27 215.37

15005 99.50 73.28

15040 203.42 102.52

15050 446.99 355.49

15100 685.04 574.75

15101 148.84 89.56

15110 632.05 551.08

15111 92.34 83.22

15115 636.06 555.09

15116 130.15 118.75

15120 677.64 558.78

15121 202.65 128.22

15130 532.87 449.37

15131 71.76 65.77

15135 666.96 585.19

CODE NOTE NFAC FAC 26 TC

15136 68.54 64.26

15150 546.96 501.62

15151 96.41 89.00

15152 118.03 110.91

15155 570.10 527.91

15156 130.12 123.28

15157 146.20 136.51

15200 663.45 540.31

15201 116.94 63.08

15220 615.41 494.54

15221 109.10 57.51

15240 744.47 644.41

15241 147.25 89.40

15260 807.02 690.49

15261 171.45 112.45

15271 123.76 74.49

15272 23.24 14.64

15273 253.76 177.76

15274 59.63 37.37

15275 132.51 86.20

15276 28.62 20.90

15277 260.27 182.66

15278 70.03 46.44

15570 729.59 590.82

15572 710.26 600.52

15574 726.79 614.21

15576 641.91 537.60

15600 258.73 166.21

15610 285.20 194.85

15620 349.08 260.73

15630 366.56 278.22

15650 403.67 307.64

15730 1369.01 807.72

15731 895.83 806.07

15733 925.42 925.42

15734 1200.98 1058.42

15736 1053.36 913.16

15738 1116.72 985.06

15740 811.75 684.63

15750 735.14 735.14

15756 1856.40 1856.40

15757 1828.61 1828.61

15758 1834.57 1834.57

Maryland Medical Assistance FS-13

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

15760 679.54 568.10

15770 535.33 535.33

15775 N.C. N.C.

15776 N.C. N.C.

15777 182.07 182.07

15780 P 686.71 517.99

15781 P 443.32 347.56

15782 P 511.01 359.39

15783 N.C. N.C.

15786 P 195.31 108.38

15787 P 39.45 13.41

15788 P 368.52 197.49

15789 P 444.69 340.68

15792 P 350.75 207.40

15793 P 395.43 295.98

15819 P 634.87 634.87

15820 P 465.38 418.38

15821 P 480.00 430.42

15822 P 353.30 309.70

15823 P 479.65 429.48

15824 P 218.00 218.00

15825 P 205.00 205.00

15826 P 185.00 185.00

15828 P 656.00 656.00

15829 656.00 656.00

15830 P 941.61 941.61

15832 P 732.71 732.71

15833 P 684.00 684.00

15834 P 711.15 711.15

15835 P 731.64 731.64

15836 P 631.24 631.24

15837 P 682.44 570.72

15838 P 453.27 453.27

15839 P 703.52 590.11

15840 801.76 801.76

15841 1267.48 1267.48

15842 1942.96 1942.96

15845 792.99 792.99

15847 P 312.72 312.72

15850 N.C. N.C.

15851 78.50 36.03

15852 37.36 37.36

15860 87.94 87.94

CODE NOTE NFAC FAC 26 TC

15876 N.C. N.C.

15877 N.C. N.C.

15878 N.C. N.C.

15879 N.C. N.C.

15920 498.37 498.37

15922 626.37 626.37

15931 552.06 552.06

15933 678.04 678.04

15934 747.71 747.71

15935 884.52 884.52

15936 713.76 713.76

15937 826.54 826.54

15940 561.02 561.02

15941 719.60 719.60

15944 712.59 712.59

15945 787.02 787.02

15946 1310.17 1310.17

15950 475.03 475.03

15951 695.25 695.25

15952 719.01 719.01

15953 797.09 797.09

15956 920.49 920.49

15958 939.48 939.48

15999 REPORT REPORT REPORT

16000 54.58 36.34

16020 65.11 43.16

16025 117.04 88.82

16030 147.83 107.07

16035 154.32 154.32

16036 65.13 65.13

17000 53.00 42.46

17003 5.47 3.59

17004 123.69 96.08

17106 273.93 232.37

17107 423.96 347.52

17108 537.14 448.67

17110 88.50 56.00

17111 104.95 68.75

17250 63.15 29.52

17260 75.37 56.27

17261 114.03 73.28

17262 139.12 93.22

17263 151.94 103.20

Maryland Medical Assistance FS-14

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

17264 162.28 109.83

17266 184.83 129.25

17270 119.84 80.22

17271 129.85 88.80

17272 147.99 102.10

17273 165.28 115.70

17274 195.33 141.46

17276 225.21 168.77

17280 112.36 73.03

17281 141.53 100.20

17282 162.45 115.14

17283 194.42 143.97

17284 221.92 168.06

17286 284.12 225.11

17311 527.20 303.46

17312 310.24 161.45

17313 493.00 272.09

17314 297.72 149.81

17315 63.81 42.72

17340 40.77 38.77

17360 102.03 78.65

17380 N.C. N.C.

17999 REPORT REPORT REPORT

19000 90.02 34.72

19001 21.33 17.34

19020 378.93 246.12

19030 131.28 61.74

19081 560.46 151.32

19082 459.58 72.61

19083 556.79 139.20

19084 447.68 67.15

19085 844.09 168.82

19086 673.43 74.08

19100 120.65 56.23

19101 273.03 177.82

19105 1891.10 159.42

19110 389.02 275.58

19112 368.89 251.77

19120 395.48 332.48

19125 438.40 369.13

19126 130.37 130.37

19260 968.18 968.18

19271 1310.15 1310.15

CODE NOTE NFAC FAC 26 TC

19272 1432.76 1432.76

19281 200.15 84.06

19282 139.37 40.33

19283 227.75 84.27

19284 167.56 41.00

19285 415.51 69.89

19286 363.25 35.89

19287 721.07 115.37

19288 574.44 51.70

19294 144.94 144.94

19296 3383.91 169.87

19297 76.63 76.63

19298 974.95 250.56

19300 419.59 332.11

19301 524.53 524.53

19302 723.93 723.93

19303 812.83 812.83

19304 464.00 464.00

19305 908.71 908.71

19306 954.54 954.54

19307 962.94 962.94

19316 P 617.96 617.96

19318 P 883.96 883.96

19324 P 397.42 397.42

19325 P 514.69 514.69

19328 397.20 397.20

19330 508.34 508.34

19340 805.07 805.07

19342 739.67 739.67

19350 659.10 540.26

19355 559.28 458.39

19357 1209.77 1209.77

19361 1263.96 1263.96

19364 2210.66 2210.66

19366 1131.93 1131.93

19367 1434.28 1434.28

19368 1766.72 1766.72

19369 1623.34 1623.34

19370 550.47 550.47

19371 629.02 629.02

19380 620.69 620.69

19396 234.38 117.24

19499 REPORT REPORT REPORT

Maryland Medical Assistance FS-15

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

20005 284.10 225.06

20100 560.97 560.97

20101 369.21 190.29

20102 431.37 229.10

20103 526.64 335.05

20150 873.00 873.00

20200 179.71 87.88

20205 244.71 138.90

20206 249.31 60.66

20220 170.72 75.97

20225 578.61 116.01

20240 168.51 168.51

20245 390.98 390.98

20250 359.58 359.58

20251 400.20 400.20

20500 110.56 90.73

20501 124.99 37.95

20520 177.88 134.82

20525 436.68 237.25

20526 72.19 55.72

20527 81.44 63.52

20550 55.68 39.49

20551 54.91 41.14

20552 49.68 33.24

20553 55.25 36.75

20555 308.81 308.81

20600 52.12 38.75

20604 77.19 48.52

20605 54.87 40.05

20606 84.75 54.90

20610 66.20 47.91

20611 97.57 64.97

20612 56.15 41.59

20615 203.48 151.25

20650 186.37 149.30

20660 243.83 221.47

20661 441.58 441.58

20662 444.42 444.42

20663 424.01 424.01

20664 718.49 718.49

20665 115.09 97.04

20670 370.27 143.07

20680 552.55 380.32

CODE NOTE NFAC FAC 26 TC

20690 477.55 477.55

20692 897.03 897.03

20693 440.42 440.42

20694 401.45 322.16

20696 1047.65 1047.65

20697 1702.50 1702.50

20802 2278.94 2278.94

20805 2882.28 2882.28

20808 3872.92 3872.92

20816 2189.48 2189.48

20822 1863.05 1863.05

20824 2156.51 2156.51

20827 1927.89 1927.89

20838 2227.10 2227.10

20900 405.93 209.66

20902 316.55 316.55

20910 409.47 409.47

20912 459.59 459.59

20920 383.50 383.50

20922 566.36 459.71

20924 484.08 484.08

20926 415.06 415.06

20930 61.00 61.00

20931 110.40 110.40

20936 94.00 94.00

20937 166.89 166.89

20938 182.11 182.11

20939 59.50 59.50

20950 232.24 88.14

20955 2418.90 2418.90

20956 2577.68 2577.68

20957 2418.15 2418.15

20962 2356.19 2356.19

20969 2687.89 2687.89

20970 2700.06 2700.06

20972 2398.41 2398.41

20973 2608.16 2608.16

20974 62.04 46.20

20975 172.21 172.21

20979 50.93 35.26

20982 1888.51 388.28

20983 7004.92 406.29

20985 143.57 143.57

Maryland Medical Assistance FS-16

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

20999 REPORT REPORT REPORT

21010 685.11 685.11

21011 319.30 248.73

21012 340.02 340.02

21013 494.51 399.56

21014 524.39 418.88

21015 567.77 567.77

21016 1052.94 818.56

21025 835.49 712.34

21026 551.15 456.35

21029 701.95 592.02

21030 459.05 379.36

21031 354.65 273.51

21032 361.52 269.26

21034 1251.03 1113.17

21040 460.68 374.35

21044 826.77 826.77

21045 1145.50 1145.50

21046 1022.01 1022.01

21047 1236.57 1236.57

21048 1038.35 1038.35

21049 1183.44 1183.44

21050 807.67 807.67

21060 745.14 745.14

21070 609.93 609.93

21073 344.25 223.52

21076 924.64 808.32

21077 2272.11 2036.95

21079 1556.42 1350.51

21080 1770.63 1522.03

21081 1613.16 1382.96

21082 1504.63 1284.35

21083 1429.17 1189.07

21084 1611.17 1345.81

21085 657.69 548.64

21086 1663.01 1497.54

21087 1653.19 1488.53

21088 1273.04 1273.04

21089 REPORT REPORT REPORT

21100 674.60 373.80

21110 685.14 593.13

21116 140.94 41.06

21120 581.14 467.18

CODE NOTE NFAC FAC 26 TC

21121 710.84 609.83

21122 680.26 680.26

21123 797.85 797.85

21125 2820.54 693.29

21127 3553.23 819.37

21137 686.41 686.41

21138 851.99 851.99

21139 918.75 918.75

21141 1264.40 1264.40

21142 1236.52 1236.52

21143 1299.79 1299.79

21145 1459.33 1459.33

21146 1451.35 1451.35

21147 1556.15 1556.15

21150 1604.29 1604.29

21151 1771.84 1771.84

21154 1952.49 1952.49

21155 2266.89 2266.89

21159 2672.25 2672.25

21160 2754.14 2754.14

21172 1682.30 1682.30

21175 1958.93 1958.93

21179 1389.07 1389.07

21180 1576.16 1576.16

21181 676.02 676.02

21182 1909.98 1909.98

21183 2195.03 2195.03

21184 2291.33 2291.33

21188 1543.15 1543.15

21193 1176.70 1176.70

21194 1336.53 1336.53

21195 1267.62 1267.62

21196 1381.46 1381.46

21198 1081.54 1081.54

21199 957.73 957.73

21206 1051.88 1051.88

21208 1550.68 778.75

21209 759.93 604.30

21210 1843.41 782.71

21215 3259.21 817.08

21230 729.84 729.84

21235 674.98 528.17

21240 1059.62 1059.62

Maryland Medical Assistance FS-17

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

21242 969.05 969.05

21243 1584.29 1584.29

21244 982.21 982.21

21245 1065.50 859.11

21246 810.98 810.98

21247 1537.56 1537.56

21248 989.20 829.64

21249 1387.19 1180.36

21255 1322.28 1322.28

21256 1084.62 1084.62

21260 1163.37 1163.37

21261 2072.57 2072.57

21263 1818.43 1818.43

21267 1461.47 1461.47

21268 1728.79 1728.79

21270 847.91 652.47

21275 756.96 756.96

21280 486.63 486.63

21282 325.27 325.27

21295 163.81 163.81

21296 381.99 381.99

21299 REPORT REPORT REPORT

21310 106.65 26.87

21315 242.38 138.69

21320 233.53 129.84

21325 438.61 438.61

21330 538.80 538.80

21335 692.34 692.34

21336 599.89 599.89

21337 362.50 266.44

21338 691.72 691.72

21339 769.28 769.28

21340 747.71 747.71

21343 1085.71 1085.71

21344 1421.05 1421.05

21345 750.49 616.15

21346 898.71 898.71

21347 1043.83 1043.83

21348 1111.62 1111.62

21355 406.21 296.78

21356 456.42 350.80

21360 497.91 497.91

21365 1032.14 1032.14

CODE NOTE NFAC FAC 26 TC

21366 1166.73 1166.73

21385 672.30 672.30

21386 624.66 624.66

21387 703.51 703.51

21390 712.12 712.12

21395 905.27 905.27

21400 163.02 132.89

21401 438.73 268.77

21406 507.97 507.97

21407 598.90 598.90

21408 818.19 818.19

21421 684.64 580.37

21422 633.22 633.22

21423 752.49 752.49

21431 690.77 690.77

21432 628.61 628.61

21433 1575.63 1575.63

21435 1240.59 1240.59

21436 1776.79 1776.79

21440 475.75 403.29

21445 683.74 577.90

21450 501.36 428.81

21451 665.88 577.72

21452 559.25 305.63

21453 766.19 697.16

21454 519.05 519.05

21461 1735.86 859.77

21462 1852.31 946.35

21465 860.00 860.00

21470 1112.82 1112.82

21480 84.47 30.45

21485 588.62 516.57

21490 869.86 869.86

21497 600.47 516.40

21499 REPORT REPORT REPORT

21501 405.89 296.10

21502 495.98 495.98

21510 438.94 438.94

21550 237.73 147.94

21552 481.20 359.26

21554 743.25 743.25

21555 400.75 305.45

21556 424.60 424.60

Maryland Medical Assistance FS-18

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

21557 770.20 770.20

21558 1394.48 1394.48

21600 518.71 518.71

21610 1015.43 1015.43

21615 644.68 644.68

21616 793.46 793.46

21620 498.72 498.72

21627 524.28 524.28

21630 1196.80 1196.80

21632 1182.65 1182.65

21685 927.59 927.59

21700 396.99 396.99

21705 591.15 591.15

21720 403.28 403.28

21725 503.24 503.24

21740 1024.35 1024.35

21742 803.78 803.78

21743 REPORT REPORT REPORT

21750 680.65 680.65

21811 571.72 592.93

21812 683.69 704.88

21813 934.22 950.76

21820 121.18 122.69

21825 541.90 541.90

21899 REPORT REPORT REPORT

21920 233.08 144.32

21925 391.42 311.61

21930 436.70 343.46

21931 474.66 474.66

21932 681.68 681.68

21933 751.09 751.09

21935 1087.49 1087.49

21936 1452.40 1452.40

22010 844.58 844.58

22015 838.73 838.73

22100 769.30 769.30

22101 766.00 766.00

22102 768.11 768.11

22103 139.08 139.08

22110 947.41 947.41

22112 940.44 940.44

22114 944.31 944.31

22116 139.80 139.80

CODE NOTE NFAC FAC 26 TC

22206 2217.30 2217.30

22207 2189.30 2189.30

22208 559.51 559.51

22210 1673.33 1673.33

22212 1378.23 1378.23

22214 1392.39 1392.39

22216 365.44 365.44

22220 1515.18 1515.18

22222 1373.72 1373.72

22224 1488.80 1488.80

22226 363.82 363.82

22310 262.58 243.44

22315 806.64 708.96

22318 1511.71 1511.71

22319 1660.16 1660.16

22325 1308.76 1308.76

22326 1374.79 1374.79

22327 1353.22 1353.22

22328 274.10 274.10

22505 118.95 118.95

22510 1863.03 479.36

22511 1847.01 449.38

22512 1054.99 217.64

22513 7997.25 547.81

22514 7951.85 512.10

22515 4854.20 228.15

22526 1861.50 334.33

22527 1574.45 151.78

22532 1626.07 1626.07

22533 1510.12 1510.12

22534 359.51 359.51

22548 1753.57 1753.57

22551 1844.50 1844.50

22552 428.47 428.47

22554 1235.29 1235.29

22556 1562.63 1562.63

22558 1416.90 1416.90

22585 334.35 334.35

22586 1646.97 1646.97

22590 1454.06 1454.06

22595 1382.55 1382.55

22600 1183.44 1183.44

22610 1168.24 1168.24

Maryland Medical Assistance FS-19

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

22612 1509.53 1509.53

22614 389.32 389.32

22630 1457.63 1457.63

22632 316.79 316.79

22633 2006.97 2006.97

22634 540.78 540.78

22800 1287.25 1287.25

22802 2045.16 2045.16

22804 2366.85 2366.85

22808 1735.09 1735.09

22810 1937.88 1937.88

22812 2120.48 2120.48

22818 2131.75 2131.75

22819 2417.54 2417.54

22830 771.98 771.98

22840 762.10 762.10

22841 200.00 200.00

22842 762.12 762.12

22843 805.78 805.78

22844 988.68 988.68

22845 730.09 730.09

22846 758.70 758.70

22847 831.71 831.71

22848 359.74 359.74

22849 1243.39 1243.39

22850 682.36 682.36

22852 652.62 652.62

22853 266.68 266.68

22854 345.21 345.21

22855 1054.73 1054.73

22856 1612.07 1612.07

22857 1646.93 1646.93

22858 565.48 565.48

22859 345.21 345.21

22861 1943.36 1943.36

22862 1916.66 1916.66

22864 1809.21 1809.21

22865 1910.87 1910.87

22867 998.44 998.44

22868 248.92 248.92

22869 548.20 548.20

22870 144.92 144.92

22899 REPORT REPORT REPORT

CODE NOTE NFAC FAC 26 TC

22900 454.83 454.83

22901 670.16 670.16

22902 425.49 338.90

22903 443.64 443.64

22904 1048.07 1048.07

22905 1359.40 1359.40

22999 REPORT REPORT REPORT

23000 495.64 339.36

23020 658.81 658.81

23030 396.06 245.48

23031 361.60 203.40

23035 654.77 654.77

23040 686.03 686.03

23044 545.18 545.18

23065 195.91 153.57

23066 471.12 320.55

23071 421.92 421.92

23073 698.32 698.32

23075 376.97 262.97

23076 528.60 528.60

23077 1107.53 1107.53

23078 1414.43 1414.43

23100 463.61 463.61

23101 426.84 426.84

23105 607.43 607.43

23106 452.55 452.55

23107 632.39 632.39

23120 535.91 535.91

23125 669.51 669.51

23130 575.30 575.30

23140 485.79 485.79

23145 656.01 656.01

23146 573.67 573.67

23150 617.42 617.42

23155 750.65 750.65

23156 641.46 641.46

23170 504.30 504.30

23172 515.46 515.46

23174 715.93 715.93

23180 654.32 654.32

23182 630.81 630.81

23184 712.86 712.86

23190 528.48 528.48

Maryland Medical Assistance FS-20

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

23195 711.89 711.89

23200 1214.46 1214.46

23210 1420.99 1420.99

23220 1565.30 1565.30

23330 208.03 140.17

23333 474.57 474.57

23334 1117.79 1117.79

23335 1331.95 1331.95

23350 143.37 50.06

23395 1224.25 1224.25

23397 1095.97 1095.97

23400 933.53 933.53

23405 603.17 603.17

23406 753.00 753.00

23410 806.34 806.34

23412 843.37 843.37

23415 671.02 671.02

23420 941.06 941.06

23430 710.97 710.97

23440 733.88 733.88

23450 917.87 917.87

23455 976.71 976.71

23460 1057.22 1057.22

23462 1033.50 1033.50

23465 1076.03 1076.03

23466 1057.93 1057.93

23470 1173.06 1173.06

23472 1444.66 1444.66

23473 1760.15 1760.15

23474 1901.48 1901.48

23480 790.11 790.11

23485 926.41 926.41

23490 779.84 779.84

23491 979.50 979.50

23500 192.04 190.68

23505 317.85 301.45

23515 648.67 648.67

23520 199.58 200.72

23525 309.03 289.22

23530 513.86 513.86

23532 592.17 592.17

23540 196.36 192.45

23545 282.80 260.69

CODE NOTE NFAC FAC 26 TC

23550 544.75 544.75

23552 627.87 627.87

23570 205.97 208.65

23575 351.14 331.30

23585 865.78 865.78

23600 288.03 266.69

23605 426.69 394.69

23615 817.62 817.62

23616 1255.64 1255.64

23620 237.36 224.02

23625 345.71 325.14

23630 686.54 686.54

23650 265.02 241.91

23655 353.56 353.56

23660 551.86 551.86

23665 384.13 362.00

23670 764.06 764.06

23675 502.71 466.11

23680 841.29 841.29

23700 186.19 186.19

23800 978.57 978.57

23802 1156.60 1156.60

23900 1271.46 1271.46

23920 1029.31 1029.31

23921 374.46 374.46

23929 REPORT REPORT REPORT

23930 328.07 204.72

23931 256.21 148.32

23935 471.65 471.65

24000 447.27 447.27

24006 676.50 676.50

24065 227.68 152.34

24066 544.31 373.34

24071 409.24 409.24

24073 702.12 702.12

24075 440.57 291.61

24076 444.57 444.57

24077 833.98 833.98

24079 1304.37 1304.37

24100 377.39 377.39

24101 471.37 471.37

24102 585.16 585.16

24105 316.05 316.05

Maryland Medical Assistance FS-21

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

24110 553.28 553.28

24115 639.12 639.12

24116 831.32 831.32

24120 495.38 495.38

24125 560.44 560.44

24126 598.78 598.78

24130 478.43 478.43

24134 719.56 719.56

24136 569.36 569.36

24138 625.17 625.17

24140 685.06 685.06

24145 574.37 574.37

24147 597.31 597.31

24149 1086.80 1086.80

24150 1253.72 1253.72

24152 1072.81 1072.81

24155 802.55 802.55

24160 1017.37 1017.37

24164 586.80 586.80

24200 181.83 126.94

24201 510.97 343.63

24220 164.17 65.72

24300 367.63 367.63

24301 717.68 717.68

24305 549.03 549.03

24310 449.83 449.83

24320 727.97 727.97

24330 685.53 685.53

24331 754.57 754.57

24332 569.50 569.50

24340 584.74 584.74

24341 680.38 680.38

24342 753.35 753.35

24343 667.39 667.39

24344 1036.46 1036.46

24345 663.21 663.21

24346 1033.27 1033.27

24357 418.10 418.10

24358 493.72 493.72

24359 607.32 607.32

24360 856.98 856.98

24361 962.46 962.46

24362 936.98 936.98

CODE NOTE NFAC FAC 26 TC

24363 1406.22 1406.22

24365 611.25 611.25

24366 654.76 654.76

24370 1662.84 1662.84

24371 1915.17 1915.17

24400 786.95 786.95

24410 1005.06 1005.06

24420 932.86 932.86

24430 983.26 983.26

24435 1009.41 1009.41

24470 602.93 602.93

24495 589.56 589.56

24498 837.29 837.29

24500 313.12 283.69

24505 456.74 418.60

24515 839.38 839.38

24516 829.00 829.00

24530 337.52 306.27

24535 572.07 533.57

24538 710.79 710.79

24545 852.12 852.12

24546 1021.43 1021.43

24560 281.34 249.21

24565 469.87 435.57

24566 655.20 655.20

24575 708.42 708.42

24576 296.11 266.38

24577 488.58 451.59

24579 797.97 797.97

24582 739.56 739.56

24586 1051.24 1051.24

24587 1042.53 1042.53

24600 328.67 299.71

24605 429.65 429.65

24615 684.23 684.23

24620 518.40 518.40

24635 732.14 732.14

24640 108.32 78.84

24650 228.55 205.47

24655 395.27 362.86

24665 617.53 617.53

24666 698.80 698.80

24670 256.97 230.66

Maryland Medical Assistance FS-22

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

24675 418.52 386.13

24685 621.86 621.86

24800 758.06 758.06

24802 947.95 947.95

24900 674.00 674.00

24920 666.13 666.13

24925 512.58 512.58

24930 702.09 702.09

24931 745.07 745.07

24935 976.12 976.12

24940 327.00 327.00

24999 REPORT REPORT REPORT

25000 327.80 327.80

25001 309.87 309.87

25020 542.91 542.91

25023 1044.29 1044.29

25024 709.11 709.11

25025 1074.25 1074.25

25028 483.26 483.26

25031 355.28 355.28

25035 616.17 616.17

25040 544.24 544.24

25065 227.90 152.99

25066 356.05 356.05

25071 428.74 428.74

25073 534.47 534.47

25075 383.34 311.23

25076 420.82 420.82

25077 715.35 715.35

25078 1138.91 1138.91

25085 438.29 438.29

25100 325.12 325.12

25101 383.85 383.85

25105 466.38 466.38

25107 577.47 577.47

25109 481.54 481.54

25110 341.14 341.14

25111 295.76 295.76

25112 361.56 361.56

25115 761.49 761.49

25116 617.82 617.82

25118 362.56 362.56

25119 480.60 480.60

CODE NOTE NFAC FAC 26 TC

25120 528.19 528.19

25125 612.54 612.54

25126 621.41 621.41

25130 425.27 425.27

25135 530.73 530.73

25136 471.25 471.25

25145 541.87 541.87

25150 551.32 551.32

25151 609.96 609.96

25170 1189.74 1189.74

25210 465.79 465.79

25215 600.47 600.47

25230 412.75 412.75

25240 418.96 418.96

25246 166.62 73.16

25248 415.85 415.85

25250 495.75 495.75

25251 674.45 674.45

25259 368.36 368.36

25260 646.43 646.43

25263 645.26 645.26

25265 765.74 765.74

25270 519.53 519.53

25272 584.73 584.73

25274 692.75 692.75

25275 636.11 636.11

25280 591.65 591.65

25290 482.05 482.05

25295 551.10 551.10

25300 648.71 648.71

25301 618.91 618.91

25310 641.03 641.03

25312 741.32 741.32

25315 795.38 795.38

25316 917.79 917.79

25320 911.40 911.40

25332 806.32 806.32

25335 868.91 868.91

25337 840.49 840.49

25350 707.10 707.10

25355 795.79 795.79

25360 686.27 686.27

25365 935.36 935.36

Maryland Medical Assistance FS-23

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

25370 1018.62 1018.62

25375 970.21 970.21

25390 798.85 798.85

25391 1015.54 1015.54

25392 1028.66 1028.66

25393 1161.09 1161.09

25394 730.40 730.40

25400 839.27 839.27

25405 1065.55 1065.55

25415 1001.79 1001.79

25420 1191.43 1191.43

25425 1030.04 1030.04

25426 1078.70 1078.70

25430 666.52 666.52

25431 753.48 753.48

25440 745.49 745.49

25441 895.23 895.23

25442 765.44 765.44

25443 734.99 734.99

25444 784.40 784.40

25445 689.97 689.97

25446 1124.04 1124.04

25447 770.21 770.21

25449 987.45 987.45

25450 568.55 568.55

25455 647.01 647.01

25490 725.85 725.85

25491 767.67 767.67

25492 927.36 927.36

25500 233.79 212.23

25505 458.96 424.63

25515 638.27 638.27

25520 506.62 483.37

25525 776.06 776.06

25526 946.53 946.53

25530 227.13 204.26

25535 444.97 417.52

25545 599.69 599.69

25560 236.86 209.41

25565 480.05 440.40

25574 619.99 619.99

25575 844.88 844.88

25600 262.20 247.96

CODE NOTE NFAC FAC 26 TC

25605 562.25 528.29

25606 626.34 626.34

25607 662.68 662.68

25608 756.84 756.84

25609 963.96 963.96

25622 265.22 238.25

25624 420.65 384.81

25628 674.16 674.16

25630 271.71 243.34

25635 398.00 348.05

25645 537.21 537.21

25650 282.85 258.07

25651 442.41 442.41

25652 583.10 583.10

25660 368.26 368.26

25670 579.28 579.28

25671 488.67 488.67

25675 389.79 359.70

25676 600.39 600.39

25680 421.88 421.88

25685 693.52 693.52

25690 432.94 432.94

25695 601.52 601.52

25800 711.72 711.72

25805 820.25 820.25

25810 825.95 825.95

25820 582.26 582.26

25825 715.65 715.65

25830 894.25 894.25

25900 711.86 711.86

25905 705.07 705.07

25907 614.55 614.55

25909 694.51 694.51

25915 1113.16 1113.16

25920 648.46 648.46

25922 536.33 536.33

25924 635.51 635.51

25927 739.29 739.29

25929 532.69 532.69

25931 674.15 674.15

25999 REPORT REPORT REPORT

26010 231.73 123.07

26011 354.73 172.90

Maryland Medical Assistance FS-24

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

26020 398.70 398.70

26025 389.93 389.93

26030 460.63 460.63

26034 499.84 499.84

26035 760.38 760.38

26037 538.00 538.00

26040 286.32 286.32

26045 437.50 437.50

26055 518.24 273.89

26060 245.17 245.17

26070 275.58 275.58

26075 294.74 294.74

26080 356.54 356.54

26100 299.14 299.14

26105 306.75 306.75

26110 294.02 294.02

26111 416.05 416.05

26113 547.36 547.36

26115 557.40 333.49

26116 448.86 448.86

26117 610.96 610.96

26118 1072.77 1072.77

26121 563.76 563.76

26123 763.49 763.49

26125 270.98 270.98

26130 428.21 428.21

26135 519.63 519.63

26140 471.96 471.96

26145 480.15 480.15

26160 518.70 298.36

26170 376.79 376.79

26180 412.42 412.42

26185 485.66 485.66

26200 424.20 424.20

26205 569.55 569.55

26210 410.57 410.57

26215 520.45 520.45

26230 474.86 474.86

26235 465.87 465.87

26236 412.62 412.62

26250 864.63 864.63

26260 645.55 645.55

26262 504.73 504.73

CODE NOTE NFAC FAC 26 TC

26320 320.80 320.80

26340 288.17 288.17

26341 106.64 80.12

26350 668.17 668.17

26352 759.06 759.06

26356 877.39 877.39

26357 816.13 816.13

26358 862.53 862.53

26370 723.77 723.77

26372 839.45 839.45

26373 796.79 796.79

26390 782.35 782.35

26392 914.98 914.98

26410 531.46 531.46

26412 645.24 645.24

26415 674.74 674.74

26416 718.22 718.22

26418 533.49 533.49

26420 670.90 670.90

26426 539.88 539.88

26428 704.50 704.50

26432 464.88 464.88

26433 498.77 498.77

26434 598.28 598.28

26437 583.05 583.05

26440 585.36 585.36

26442 884.00 884.00

26445 543.33 543.33

26449 709.61 709.61

26450 376.58 376.58

26455 373.95 373.95

26460 363.54 363.54

26471 574.41 574.41

26474 550.18 550.18

26476 536.33 536.33

26477 541.35 541.35

26478 587.66 587.66

26479 581.68 581.68

26480 706.80 706.80

26483 798.23 798.23

26485 764.38 764.38

26489 824.20 824.20

26490 738.13 738.13

Maryland Medical Assistance FS-25

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

26492 822.89 822.89

26494 748.02 748.02

26496 811.57 811.57

26497 811.56 811.56

26498 1085.30 1085.30

26499 775.86 775.86

26500 586.26 586.26

26502 662.74 662.74

26508 590.46 590.46

26510 558.41 558.41

26516 660.40 660.40

26517 778.35 778.35

26518 784.46 784.46

26520 612.01 612.01

26525 614.64 614.64

26530 504.01 504.01

26531 586.02 586.02

26535 366.92 366.92

26536 629.10 629.10

26540 619.90 619.90

26541 757.31 757.31

26542 640.71 640.71

26545 652.32 652.32

26546 914.22 914.22

26548 718.15 718.15

26550 1405.21 1405.21

26551 2954.49 2954.49

26553 2632.97 2632.97

26554 3386.83 3386.83

26555 1299.86 1299.86

26556 2726.31 2726.31

26560 534.18 534.18

26561 853.65 853.65

26562 1170.41 1170.41

26565 634.66 634.66

26567 641.43 641.43

26568 845.99 845.99

26580 1226.26 1226.26

26587 897.40 897.40

26590 1206.13 1206.13

26591 408.01 408.01

26593 557.06 557.06

26596 692.88 692.88

CODE NOTE NFAC FAC 26 TC

26600 245.99 220.75

26605 285.88 261.12

26607 410.35 410.35

26608 444.24 444.24

26615 497.88 497.88

26641 324.80 292.35

26645 374.29 342.92

26650 445.84 445.84

26665 562.07 562.07

26670 293.60 263.54

26675 400.31 370.57

26676 465.72 465.72

26685 523.01 523.01

26686 585.59 585.59

26700 279.45 258.35

26705 366.61 337.24

26706 403.38 403.38

26715 502.72 502.72

26720 170.95 155.80

26725 306.51 275.64

26727 436.40 436.40

26735 520.62 520.62

26740 199.52 187.33

26742 335.47 305.34

26746 620.08 620.08

26750 159.43 154.57

26755 280.48 243.85

26756 384.64 384.64

26765 419.60 419.60

26770 237.00 215.43

26775 341.34 305.87

26776 409.20 409.20

26785 454.39 454.39

26820 741.14 741.14

26841 686.79 686.79

26842 745.67 745.67

26843 689.44 689.44

26844 769.28 769.28

26850 653.41 653.41

26852 748.26 748.26

26860 524.08 524.08

26861 102.75 102.75

26862 681.00 681.00

Maryland Medical Assistance FS-26

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

26863 229.07 229.07

26910 670.77 670.77

26951 577.19 577.19

26952 607.48 607.48

26989 REPORT REPORT REPORT

26990 584.79 584.79

26991 653.56 489.45

26992 919.86 919.86

27000 426.05 426.05

27001 517.09 517.09

27003 552.12 552.12

27005 695.69 695.69

27006 704.65 704.65

27025 842.12 842.12

27027 833.46 833.46

27030 906.69 906.69

27033 937.44 937.44

27035 1050.49 1050.49

27036 954.31 954.31

27040 316.20 187.29

27041 645.84 645.84

27043 473.90 473.90

27045 752.54 752.54

27047 511.32 402.31

27048 491.95 491.95

27049 1069.18 1069.18

27050 329.32 329.32

27052 523.15 523.15

27054 646.65 646.65

27057 915.81 915.81

27059 1841.60 1841.60

27060 404.89 404.89

27062 427.14 427.14

27065 469.93 469.93

27066 767.94 767.94

27067 963.06 963.06

27070 805.20 805.20

27071 869.19 869.19

27075 2185.63 2185.63

27076 2032.07 2032.07

27077 2547.69 2547.69

27078 1657.04 1657.04

27080 458.42 458.42

CODE NOTE NFAC FAC 26 TC

27086 227.83 140.16

27087 598.75 598.75

27090 797.57 797.57

27091 1515.96 1515.96

27093 184.83 68.50

27095 223.02 77.03

27096 168.60 66.04

27097 631.21 631.21

27098 588.78 588.78

27100 779.33 779.33

27105 806.80 806.80

27110 900.99 900.99

27111 820.89 820.89

27120 1228.48 1228.48

27122 1059.25 1059.25

27125 1068.22 1068.22

27130 1379.08 1379.08

27132 1613.10 1613.10

27134 1874.61 1874.61

27137 1429.83 1429.83

27138 1487.39 1487.39

27140 863.50 863.50

27146 1214.42 1214.42

27147 1394.71 1394.71

27151 1386.78 1386.78

27156 1652.42 1652.42

27158 1289.20 1289.20

27161 1173.17 1173.17

27165 1299.08 1299.08

27170 1130.02 1130.02

27175 612.49 612.49

27176 869.55 869.55

27177 1060.09 1060.09

27178 847.88 847.88

27179 934.65 934.65

27181 1043.95 1043.95

27185 625.49 625.49

27187 957.08 957.08

27197 115.95 115.95

27198 294.52 294.52

27200 159.28 162.70

27202 608.45 608.45

27215 661.68 661.68

Maryland Medical Assistance FS-27

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

27216 977.55 977.55

27217 923.05 923.05

27218 1262.23 1262.23

27220 492.87 488.78

27222 935.33 935.33

27226 961.15 961.15

27227 1597.75 1597.75

27228 1829.51 1829.51

27230 441.60 432.41

27232 737.75 737.75

27235 873.68 873.68

27236 1127.86 1127.86

27238 425.30 425.30

27240 907.08 907.08

27244 1112.52 1112.52

27245 1236.71 1236.71

27246 361.78 362.47

27248 728.39 728.39

27250 197.14 197.14

27252 718.03 718.03

27253 908.92 908.92

27254 1219.88 1219.88

27256 276.07 233.09

27257 317.20 317.20

27258 1060.66 1060.66

27259 1473.54 1473.54

27265 367.09 367.09

27266 551.24 551.24

27267 394.39 394.39

27268 486.44 486.44

27269 1151.74 1151.74

27275 171.67 171.67

27279 608.95 608.95

27280 1104.83 1104.83

27282 777.42 777.42

27284 1510.31 1510.31

27286 1546.55 1546.55

27290 1492.83 1492.83

27295 1202.68 1202.68

27299 REPORT REPORT REPORT

27301 616.61 465.36

27303 608.33 608.33

27305 444.83 444.83

CODE NOTE NFAC FAC 26 TC

27306 360.83 360.83

27307 443.91 443.91

27310 689.60 689.60

27323 244.64 165.23

27324 359.76 359.76

27325 484.80 484.80

27326 463.50 463.50

27327 419.54 326.61

27328 499.82 499.82

27329 971.26 971.26

27330 380.08 380.08

27331 449.29 449.29

27332 607.46 607.46

27333 552.17 552.17

27334 647.80 647.80

27335 731.40 731.40

27337 422.67 422.67

27339 760.55 760.55

27340 343.47 343.47

27345 454.53 454.53

27347 478.29 478.29

27350 618.92 618.92

27355 574.76 574.76

27356 700.74 700.74

27357 778.66 778.66

27358 280.62 280.62

27360 813.44 813.44

27364 1586.83 1586.83

27365 1659.71 1659.71

27370 157.88 49.68

27372 554.11 382.95

27380 562.74 562.74

27381 768.41 768.41

27385 602.97 602.97

27386 796.88 796.88

27390 415.04 415.04

27391 543.99 543.99

27392 670.89 670.89

27393 482.38 482.38

27394 623.41 623.41

27395 841.11 841.11

27396 585.83 585.83

27397 847.44 847.44

Maryland Medical Assistance FS-28

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

27400 643.10 643.10

27403 613.21 613.21

27405 644.76 644.76

27407 739.31 739.31

27409 918.07 918.07

27412 1579.65 1579.65

27415 1335.04 1335.04

27416 906.09 906.09

27418 797.11 797.11

27420 716.13 716.13

27422 713.80 713.80

27424 714.57 714.57

27425 417.44 417.44

27427 686.28 686.28

27428 1047.44 1047.44

27429 1171.41 1171.41

27430 708.23 708.23

27435 755.06 755.06

27437 630.41 630.41

27438 801.25 801.25

27440 706.99 706.99

27441 747.09 747.09

27442 833.79 833.79

27443 783.95 783.95

27445 1211.26 1211.26

27446 1078.60 1078.60

27447 1481.55 1481.55

27448 788.78 788.78

27450 979.87 979.87

27454 1237.20 1237.20

27455 906.48 906.48

27457 932.64 932.64

27465 1139.09 1139.09

27466 1134.01 1134.01

27468 1279.14 1279.14

27470 1130.61 1130.61

27472 1223.82 1223.82

27475 625.00 625.00

27477 699.20 699.20

27479 904.00 904.00

27485 642.16 642.16

27486 1351.41 1351.41

27487 1704.47 1704.47

CODE NOTE NFAC FAC 26 TC

27488 1143.33 1143.33

27495 1089.12 1089.12

27496 477.43 477.43

27497 517.69 517.69

27498 564.33 564.33

27499 628.79 628.79

27500 482.00 445.13

27501 473.80 464.37

27502 755.40 755.40

27503 764.44 764.44

27506 1267.88 1267.88

27507 947.86 947.86

27508 485.59 458.06

27509 612.83 612.83

27510 664.11 664.11

27511 989.58 989.58

27513 1246.31 1246.31

27514 1009.75 1009.75

27516 453.28 428.12

27517 634.38 634.38

27519 910.82 910.82

27520 285.85 259.15

27524 724.40 724.40

27530 333.48 309.50

27532 577.11 546.47

27535 881.78 881.78

27536 1133.16 1133.16

27538 430.87 404.59

27540 807.72 807.72

27550 452.98 419.55

27552 590.67 590.67

27556 895.55 895.55

27557 1070.89 1070.89

27558 1193.06 1193.06

27560 329.98 287.64

27562 426.00 426.00

27566 859.95 859.95

27570 140.04 140.04

27580 1388.88 1388.88

27590 779.14 779.14

27591 872.89 872.89

27592 660.81 660.81

27594 483.99 483.99

Maryland Medical Assistance FS-29

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

27596 699.47 699.47

27598 708.79 708.79

27599 REPORT REPORT REPORT

27600 404.04 404.04

27601 415.98 415.98

27602 495.80 495.80

27603 487.67 366.39

27604 428.38 325.05

27605 340.75 194.36

27606 287.15 287.15

27607 580.93 580.93

27610 626.60 626.60

27612 544.84 544.84

27613 227.44 154.95

27614 523.36 392.99

27615 846.32 846.32

27616 1295.29 1295.29

27618 455.96 333.85

27619 516.10 516.10

27620 443.34 443.34

27625 573.31 573.31

27626 620.36 620.36

27630 501.07 356.21

27632 416.88 416.88

27634 679.04 679.04

27635 571.04 571.04

27637 718.65 718.65

27638 752.32 752.32

27640 835.14 835.14

27641 668.51 668.51

27645 1427.56 1427.56

27646 1192.00 1192.00

27647 807.82 807.82

27648 152.16 49.67

27650 653.82 653.82

27652 718.39 718.39

27654 678.64 678.64

27656 503.68 333.23

27658 369.31 369.31

27659 485.39 485.39

27664 352.38 352.38

27665 403.79 403.79

27675 494.53 494.53

CODE NOTE NFAC FAC 26 TC

27676 598.93 598.93

27680 418.93 418.93

27681 499.64 499.64

27685 587.83 461.15

27686 545.10 545.10

27687 448.29 448.29

27690 593.86 593.86

27691 705.47 705.47

27692 109.29 109.29

27695 477.24 477.24

27696 569.36 569.36

27698 639.76 639.76

27700 595.67 595.67

27702 965.29 965.29

27703 1104.54 1104.54

27704 538.21 538.21

27705 742.47 742.47

27707 376.73 376.73

27709 1023.20 1023.20

27712 1038.53 1038.53

27715 1021.16 1021.16

27720 846.59 846.59

27722 843.55 843.55

27724 1234.25 1234.25

27725 1144.69 1144.69

27726 849.50 849.50

27727 944.73 944.73

27730 563.02 563.02

27732 382.84 382.84

27734 575.87 575.87

27740 641.23 641.23

27742 632.22 632.22

27745 728.23 728.23

27750 309.41 284.25

27752 499.25 466.45

27756 541.72 541.72

27758 849.93 849.93

27759 964.39 964.39

27760 297.42 270.35

27762 446.28 413.12

27766 585.96 585.96

27767 234.90 236.05

27768 375.06 375.06

Maryland Medical Assistance FS-30

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

27769 642.90 642.90

27780 265.92 241.00

27781 386.55 361.00

27784 641.09 641.09

27786 282.06 254.00

27788 389.91 360.20

27792 655.46 655.46

27808 295.02 265.28

27810 436.54 402.62

27814 748.19 748.19

27816 278.90 251.46

27818 449.29 410.79

27822 820.13 820.13

27823 934.74 934.74

27824 280.05 269.30

27825 512.63 469.62

27826 774.23 774.23

27827 1048.25 1048.25

27828 1245.86 1245.86

27829 609.98 609.98

27830 324.07 302.49

27831 356.95 356.95

27832 643.84 643.84

27840 325.36 325.36

27842 456.30 456.30

27846 710.00 710.00

27848 808.63 808.63

27860 170.09 170.09

27870 1006.69 1006.69

27871 668.53 668.53

27880 865.49 865.49

27881 859.28 859.28

27882 608.19 608.19

27884 561.33 561.33

27886 636.74 636.74

27888 680.60 680.60

27889 662.68 662.68

27892 524.08 524.08

27893 522.13 522.13

27894 792.95 792.95

27899 REPORT REPORT REPORT

28001 248.07 177.35

28002 457.02 348.02

CODE NOTE NFAC FAC 26 TC

28003 632.22 545.92

28005 596.04 596.04

28008 392.79 300.56

28010 218.42 207.85

28011 309.46 293.99

28020 471.99 353.95

28022 430.93 326.95

28024 412.44 309.82

28035 469.03 356.84

28039 481.34 342.14

28041 450.11 450.11

28043 323.86 255.82

28045 438.55 325.36

28046 784.64 659.57

28047 943.74 943.74

28050 410.20 307.53

28052 383.70 279.64

28054 359.55 254.81

28055 383.45 383.45

28060 462.23 357.58

28062 547.02 414.70

28070 459.17 351.13

28072 450.10 340.10

28080 435.89 336.16

28086 495.79 355.88

28088 415.43 296.24

28090 416.84 308.67

28092 381.89 270.91

28100 547.02 401.79

28102 528.51 528.51

28103 430.88 430.88

28104 461.25 351.06

28106 459.14 459.14

28107 508.74 379.01

28108 386.10 289.19

28110 408.21 288.93

28111 470.06 337.32

28112 442.29 316.15

28113 517.45 405.47

28114 957.89 788.15

28116 673.57 557.11

28118 525.27 406.77

28119 469.26 360.53

Maryland Medical Assistance FS-31

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

28120 545.30 397.09

28122 605.87 484.09

28124 428.22 333.75

28126 345.19 251.26

28130 623.25 623.25

28140 580.15 454.72

28150 389.08 286.99

28153 358.28 257.71

28160 369.08 272.27

28171 668.70 668.70

28173 682.51 600.75

28175 499.17 388.70

28190 224.99 132.72

28192 431.01 319.34

28193 488.08 378.55

28200 424.99 318.66

28202 576.24 442.67

28208 406.36 304.16

28210 530.30 410.61

28220 402.82 308.44

28222 466.83 367.02

28225 353.03 255.59

28226 415.42 319.13

28230 389.18 293.64

28232 346.27 249.56

28234 356.45 261.38

28238 625.51 496.47

28240 395.00 301.50

28250 502.60 396.35

28260 619.17 513.73

28261 891.13 776.35

28262 1269.81 1098.00

28264 784.20 686.10

28270 427.50 333.45

28272 351.96 259.57

28280 481.41 363.56

28285 431.88 318.38

28286 408.86 307.05

28288 518.35 415.92

28289 669.07 512.17

28291 733.01 474.62

28292 693.79 531.51

28295 942.50 529.03

CODE NOTE NFAC FAC 26 TC

28296 737.37 538.06

28297 848.41 602.96

28298 687.91 507.13

28299 832.60 636.27

28300 651.60 651.60

28302 646.53 646.53

28304 720.40 584.39

28305 664.50 664.50

28306 543.40 396.85

28307 652.38 447.47

28308 486.94 361.55

28309 870.96 870.96

28310 483.85 355.19

28312 441.32 319.91

28313 455.68 366.91

28315 426.48 324.30

28320 618.17 618.17

28322 719.25 570.22

28340 567.28 440.66

28341 646.99 518.76

28344 453.65 299.64

28345 515.24 399.26

28360 928.90 928.90

28400 223.97 206.05

28405 366.47 343.97

28406 504.60 504.60

28415 1109.89 1109.89

28420 1167.41 1167.41

28430 209.19 186.70

28435 296.52 275.17

28436 404.05 404.05

28445 1044.65 1044.65

28446 1110.02 1110.02

28450 193.46 173.63

28455 268.69 251.14

28456 258.66 258.66

28465 587.66 587.66

28470 193.41 174.73

28475 245.72 227.41

28476 320.13 320.13

28485 503.34 503.34

28490 124.13 108.87

28495 156.93 139.40

Maryland Medical Assistance FS-32

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

28496 381.91 214.56

28505 603.30 446.14

28510 107.74 105.83

28515 141.68 130.80

28525 509.35 362.25

28530 103.99 96.37

28531 337.10 185.00

28540 184.43 172.61

28545 238.43 211.34

28546 456.70 284.20

28555 784.04 606.14

28570 159.50 143.87

28575 302.11 287.49

28576 336.93 336.93

28585 803.64 679.88

28600 192.70 173.64

28605 263.71 236.92

28606 373.63 373.63

28615 734.38 734.38

28630 135.52 104.57

28635 163.06 133.24

28636 283.57 195.07

28645 539.75 429.80

28660 99.51 79.56

28665 142.28 132.11

28666 190.18 190.18

28675 515.81 361.48

28705 1272.12 1272.12

28715 943.53 943.53

28725 784.77 784.77

28730 809.28 809.28

28735 774.48 774.48

28737 686.46 686.46

28740 789.00 608.95

28750 768.34 582.79

28755 459.64 331.81

28760 706.91 563.20

28800 557.80 557.80

28805 706.23 706.23

28810 428.18 428.18

28820 488.67 339.04

28825 435.80 297.00

28890 321.30 216.97

CODE NOTE NFAC FAC 26 TC

28899 REPORT REPORT REPORT

29000 243.40 160.91

29010 228.91 152.52

29015 219.40 154.22

29035 219.92 133.18

29040 205.86 146.82

29044 239.04 154.35

29046 255.03 179.31

29049 79.51 57.87

29055 190.13 127.03

29058 102.51 79.37

29065 86.81 65.08

29075 80.47 58.49

29085 85.65 61.94

29086 65.02 45.06

29105 79.15 55.47

29125 61.26 39.43

29126 70.11 48.04

29130 37.37 26.60

29131 45.65 29.43

29200 32.51 19.53

29240 30.94 19.53

29260 31.44 21.21

29280 31.39 21.16

29305 215.51 150.04

29325 233.67 166.07

29345 124.93 97.36

29355 129.31 103.97

29358 140.52 98.90

29365 111.90 84.42

29405 82.24 62.37

29425 86.52 62.53

29435 109.23 83.20

29440 47.88 31.36

29445 136.92 108.36

29450 143.22 121.11

29505 69.49 44.91

29515 65.18 46.86

29520 34.09 19.93

29530 30.94 19.53

29540 28.24 19.58

29550 20.69 12.43

29580 45.73 31.04

Maryland Medical Assistance FS-33

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

29581 69.02 13.95

29584 75.75 16.01

29700 59.39 32.94

29705 62.95 45.89

29710 109.73 78.83

29720 73.74 42.81

29730 61.05 43.90

29740 87.58 64.63

29750 94.02 73.26

29799 20.00 20.00

29800 493.71 493.71

29804 614.42 614.42

29805 448.90 448.90

29806 1021.15 1021.15

29807 995.75 995.75

29819 563.04 563.04

29820 519.62 519.62

29821 567.46 567.46

29822 551.11 551.11

29823 603.02 603.02

29824 640.34 640.34

29825 562.28 562.28

29826 195.75 195.75

29827 1051.57 1051.57

29828 857.85 857.85

29830 433.08 433.08

29834 471.96 471.96

29835 484.65 484.65

29836 555.81 555.81

29837 508.10 508.10

29838 567.45 567.45

29840 422.97 422.97

29843 453.75 453.75

29844 473.30 473.30

29845 537.31 537.31

29846 497.49 497.49

29847 516.03 516.03

29848 466.18 466.18

29850 524.29 524.29

29851 901.27 901.27

29855 757.72 757.72

29856 965.95 965.95

29860 621.29 621.29

CODE NOTE NFAC FAC 26 TC

29861 678.52 678.52

29862 763.22 763.22

29863 752.68 752.68

29866 1007.55 1007.55

29867 1218.29 1218.29

29868 1635.54 1635.54

29870 469.11 389.08

29871 489.88 489.88

29873 488.70 488.70

29874 510.79 510.79

29875 473.83 473.83

29876 617.85 617.85

29877 584.93 584.93

29879 625.32 625.32

29880 624.01 624.01

29881 600.60 600.60

29882 657.29 657.29

29883 807.32 807.32

29884 582.56 582.56

29885 706.49 706.49

29886 595.53 595.53

29887 702.52 702.52

29888 949.17 949.17

29889 1158.78 1158.78

29891 663.19 663.19

29892 679.34 679.34

29893 538.25 406.76

29894 498.18 498.18

29895 484.18 484.18

29897 507.57 507.57

29898 566.44 566.44

29899 1011.08 1011.08

29900 435.79 435.79

29901 477.84 477.84

29902 510.51 510.51

29904 576.59 576.59

29905 621.89 621.89

29906 655.05 655.05

29907 800.93 800.93

29914 1090.53 1090.53

29915 1110.88 1110.88

29916 1110.88 1110.88

29999 REPORT REPORT REPORT

Maryland Medical Assistance FS-34

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

30000 182.66 93.45

30020 185.22 94.30

30100 112.13 54.56

30110 183.24 103.15

30115 342.50 342.50

30117 700.38 270.56

30118 609.11 609.11

30120 415.83 350.54

30124 226.49 226.49

30125 479.92 479.92

30130 302.75 302.75

30140 350.27 350.27

30150 609.20 609.20

30160 610.93 610.93

30200 89.84 47.09

30210 119.01 79.11

30220 241.52 99.00

30300 161.27 88.25

30310 163.95 163.95

30320 358.48 358.48

30400 P 801.14 801.14

30410 P 931.29 931.29

30420 P 1084.68 1084.68

30430 P 680.16 680.16

30435 P 1000.99 1000.99

30450 P 1179.22 1179.22

30460 647.82 647.82

30462 1113.91 1113.91

30465 775.88 775.88

30520 493.44 493.44

30540 548.37 548.37

30545 701.44 701.44

30560 213.97 109.08

30580 522.66 409.50

30600 452.43 338.69

30620 496.21 496.21

30630 492.48 492.48

30801 182.79 108.69

30802 231.15 150.78

30901 75.46 44.96

30903 176.31 63.74

30905 216.47 84.23

30906 277.09 108.65

CODE NOTE NFAC FAC 26 TC

30915 454.61 454.61

30920 661.42 661.42

30930 97.65 97.65

30999 REPORT REPORT REPORT

31000 146.84 84.14

31002 151.04 151.04

31020 387.73 287.11

31030 549.97 420.29

31032 455.49 455.49

31040 603.94 603.94

31050 383.36 383.36

31051 511.33 511.33

31070 347.96 347.96

31075 621.69 621.69

31080 829.01 829.01

31081 1205.77 1205.77

31084 942.20 942.20

31085 1286.82 1286.82

31086 897.63 897.63

31087 863.14 863.14

31090 812.35 812.35

31200 454.77 454.77

31201 586.22 586.22

31205 711.52 711.52

31225 1486.62 1486.62

31230 1633.73 1633.73

31231 167.19 56.54

31233 208.49 108.44

31235 237.73 127.99

31237 232.12 135.98

31238 238.27 147.68

31239 487.37 487.37

31240 127.56 127.56

31241 392.57 392.57

31253 439.55 439.55

31254 216.55 216.55

31255 316.80 316.80

31256 156.81 156.81

31257 391.17 391.17

31259 414.78 414.78

31267 251.33 251.33

31276 399.43 399.43

31287 183.90 183.90

Maryland Medical Assistance FS-35

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

31288 213.22 213.22

31290 916.96 916.96

31291 980.53 980.53

31292 792.27 792.27

31293 860.69 860.69

31294 996.02 996.02

31295 1726.42 145.19

31296 2063.92 173.16

31297 2027.51 141.93

31298 3436.62 224.07

31299 REPORT REPORT REPORT

31300 1041.75 1041.75

31360 1681.62 1681.62

31365 2071.29 2071.29

31367 1777.87 1777.87

31368 1979.03 1979.03

31370 1676.37 1676.37

31375 1589.41 1589.41

31380 1567.90 1567.90

31382 1724.69 1724.69

31390 2310.08 2310.08

31395 2444.26 2444.26

31400 786.35 786.35

31420 661.05 661.05

31500 111.63 111.63

31502 27.85 27.85

31505 65.83 39.32

31510 169.25 97.15

31511 168.62 103.36

31512 164.45 103.74

31513 105.47 105.47

31515 149.11 82.47

31520 125.05 125.05

31525 201.62 127.81

31526 125.60 125.60

31527 155.46 155.46

31528 115.61 115.61

31529 129.17 129.17

31530 158.14 158.14

31531 169.23 169.23

31535 151.32 151.32

31536 168.43 168.43

31540 193.34 193.34

CODE NOTE NFAC FAC 26 TC

31541 210.71 210.71

31545 289.17 289.17

31546 439.27 439.27

31551 1240.89 1240.89

31552 1256.48 1256.48

31553 1370.53 1370.53

31554 1444.95 1444.95

31560 249.79 249.79

31561 273.68 273.68

31570 269.64 183.57

31571 199.70 199.70

31572 437.95 158.41

31573 231.82 130.82

31574 908.21 130.78

31575 90.76 56.85

31576 211.99 95.12

31577 219.30 112.02

31578 240.94 124.47

31579 166.66 104.33

31580 998.51 998.51

31584 1106.01 1106.01

31587 928.33 928.33

31590 701.04 701.04

31591 912.68 912.68

31592 1471.91 1471.91

31595 605.25 605.25

31599 REPORT REPORT REPORT

31600 318.00 318.00

31601 183.11 183.11

31603 178.31 178.31

31605 147.22 147.22

31610 568.65 568.65

31611 428.43 428.43

31612 66.37 38.44

31613 363.31 363.31

31614 602.06 602.06

31615 133.95 91.77

31622 236.42 107.59

31623 259.89 108.45

31624 240.83 108.47

31625 263.90 126.62

31626 675.96 160.61

31627 1127.06 78.11

Maryland Medical Assistance FS-36

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

31628 307.65 140.84

31629 430.27 150.08

31630 159.24 159.24

31631 182.94 182.94

31632 55.43 38.81

31633 65.50 50.06

31634 1529.18 169.43

31635 266.35 141.54

31636 175.24 175.24

31637 58.44 58.44

31638 199.87 199.87

31640 200.84 200.84

31641 204.87 204.87

31643 140.41 140.41

31645 229.68 118.56

31646 209.77 103.10

31647 190.37 190.37

31648 199.62 199.62

31649 62.26 62.26

31651 72.98 72.98

31652 794.13 202.03

31653 843.50 222.94

31654 100.14 58.29

31660 191.19 191.19

31661 201.84 201.84

31717 266.59 82.27

31720 41.14 41.14

31725 67.30 67.30

31730 996.09 119.63

31750 1124.38 1124.38

31755 1424.41 1424.41

31760 1123.08 1123.08

31766 1438.46 1438.46

31770 1077.14 1077.14

31775 1014.10 1014.10

31780 941.25 941.25

31781 1120.30 1120.30

31785 861.70 861.70

31786 1196.29 1196.29

31800 587.40 587.40

31805 660.31 660.31

31820 345.16 260.53

31825 477.15 380.81

CODE NOTE NFAC FAC 26 TC

31830 352.47 273.80

31899 REPORT REPORT REPORT

32035 583.90 583.90

32036 623.56 623.56

32096 N.C. N.C.

32097 703.30 703.30

32098 660.94 660.94

32100 683.15 683.15

32110 1180.28 1180.28

32120 703.67 703.67

32124 748.26 748.26

32140 795.89 795.89

32141 1228.74 1228.74

32150 811.15 811.15

32151 808.45 808.45

32160 637.71 637.71

32200 909.92 909.92

32215 642.97 642.97

32220 1277.22 1277.22

32225 801.08 801.08

32310 737.31 737.31

32320 1288.69 1288.69

32400 119.81 69.08

32405 311.74 72.60

32440 1261.76 1261.76

32442 2481.86 2481.86

32445 2863.09 2863.09

32480 1192.39 1192.39

32482 1275.82 1275.82

32484 1157.87 1157.87

32486 1896.79 1896.79

32488 1937.75 1937.75

32491 1188.38 1188.38

32501 197.42 197.42

32503 1458.37 1458.37

32504 1676.12 1676.12

32505 811.10 811.10

32506 136.53 136.53

32507 136.53 136.53

32540 1399.90 1399.90

32550 635.49 167.13

32551 128.39 128.39

32552 147.09 127.14

Maryland Medical Assistance FS-37

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

32553 429.68 150.35

32554 199.78 75.38

32555 287.22 94.32

32556 516.75 103.40

32557 507.90 140.94

32560 232.41 79.93

32561 73.20 54.39

32562 65.79 48.97

32601 248.86 248.86

32604 390.30 390.30

32606 373.36 373.36

32607 269.13 269.13

32608 330.47 330.47

32609 228.81 228.81

32650 536.82 536.82

32651 883.79 883.79

32652 1340.61 1340.61

32653 854.04 854.04

32654 955.41 955.41

32655 771.28 771.28

32656 646.39 646.39

32658 576.09 576.09

32659 590.54 590.54

32661 645.60 645.60

32662 720.11 720.11

32663 1130.14 1130.14

32664 681.14 681.14

32665 995.61 995.61

32666 759.08 759.08

32667 136.53 136.53

32668 137.47 137.47

32669 1167.89 1167.89

32670 1392.92 1392.92

32671 1546.64 1546.64

32672 1323.32 1323.32

32673 1041.63 1041.63

32674 187.09 187.09

32701 189.54 189.54

32800 762.87 762.87

32810 720.22 720.22

32815 2250.43 2250.43

32820 1137.28 1137.28

32850 P 444.00 444.00

CODE NOTE NFAC FAC 26 TC

32851 P 2663.74 2663.74

32852 P 2910.40 2910.40

32853 P 3713.76 3713.76

32854 P 3942.15 3942.15

32855 P 340.59 340.59

32856 P 401.79 401.79

32900 1135.19 1135.19

32905 1084.49 1084.49

32906 1336.12 1336.12

32940 999.59 999.59

32960 101.38 73.45

32994 5477.95 427.83

32997 269.75 269.75

32998 1934.25 224.57

32999 REPORT REPORT REPORT

33010 86.57 86.57

33011 88.65 88.65

33015 412.72 412.72

33020 710.56 710.56

33025 644.50 644.50

33030 1618.13 1618.13

33031 1994.75 1994.75

33050 805.72 805.72

33120 1694.95 1694.95

33130 1116.68 1116.68

33140 1275.33 1275.33

33141 117.70 117.70

33202 627.39 627.39

33203 650.81 650.81

33206 365.26 365.26

33207 389.44 389.44

33208 422.62 422.62

33210 133.78 133.78

33211 136.81 136.81

33212 259.19 259.19

33213 288.74 288.74

33214 386.65 386.65

33215 251.63 251.63

33216 299.91 299.91

33217 293.91 293.91

33218 315.43 315.43

33220 315.56 315.56

33221 305.11 305.11

Maryland Medical Assistance FS-38

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

33222 272.49 272.49

33223 330.28 330.28

33224 418.61 418.61

33225 381.49 381.49

33226 402.72 402.72

33227 291.24 291.24

33228 303.67 303.67

33229 316.11 316.11

33230 328.22 328.22

33231 340.65 340.65

33233 186.23 186.23

33234 392.97 392.97

33235 516.65 516.65

33236 634.14 634.14

33237 676.99 676.99

33238 754.00 754.00

33240 346.92 346.92

33241 174.72 174.72

33243 1106.56 1106.56

33244 697.09 697.09

33249 742.77 742.77

33250 1172.27 1172.27

33251 1312.87 1312.87

33254 1103.93 1103.93

33255 1329.04 1329.04

33256 1570.22 1570.22

33257 470.55 470.55

33258 528.55 528.55

33259 682.65 682.65

33261 1312.59 1312.59

33262 316.36 316.36

33263 328.80 328.80

33264 341.22 341.22

33265 1097.02 1097.02

33266 1491.91 1491.91

33270 561.75 561.75

33271 422.84 422.84

33272 384.10 384.10

33273 339.52 339.52

33282 246.16 246.16

33284 182.22 182.22

33300 1979.39 1979.39

33305 3312.18 3312.18

CODE NOTE NFAC FAC 26 TC

33310 952.25 952.25

33315 1544.38 1544.38

33320 858.37 858.37

33321 961.28 961.28

33322 1121.38 1121.38

33330 1154.89 1154.89

33335 1514.91 1514.91

33340 709.42 709.42

33361 1148.42 1148.42

33362 1256.43 1256.43

33363 1300.92 1300.92

33364 1384.53 1384.53

33365 1519.63 1519.63

33366 1604.10 1604.10

33367 533.33 533.33

33368 646.39 646.39

33369 853.35 853.35

33390 1688.17 1688.17

33391 2000.31 2000.31

33404 1417.30 1417.30

33405 1832.72 1832.72

33406 2325.10 2325.10

33410 2054.39 2054.39

33411 2710.50 2710.50

33412 2563.27 2563.27

33413 2603.44 2603.44

33414 1746.97 1746.97

33415 1641.52 1641.52

33416 1640.36 1640.36

33417 1354.55 1354.55

33418 1494.19 1566.66

33419 427.94 427.94

33420 1181.88 1181.88

33422 1350.89 1350.89

33425 2205.68 2205.68

33426 1924.04 1924.04

33427 1975.36 1975.36

33430 2259.99 2259.99

33460 1961.88 1961.88

33463 2495.62 2495.62

33464 1972.14 1972.14

33465 2228.39 2228.39

33468 1991.29 1991.29

Maryland Medical Assistance FS-39

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

33470 1052.69 1052.69

33471 1125.07 1125.07

33474 1769.18 1769.18

33475 1883.80 1883.80

33476 1235.94 1235.94

33477 1130.98 1130.98

33478 1277.12 1277.12

33496 1352.85 1352.85

33500 1263.37 1263.37

33501 900.79 900.79

33502 1036.73 1036.73

33503 1077.35 1077.35

33504 1190.66 1190.66

33505 1676.13 1676.13

33506 1669.00 1669.00

33507 1400.59 1400.59

33508 13.06 13.06

33510 1560.66 1560.66

33511 1715.49 1715.49

33512 1949.56 1949.56

33513 2006.85 2006.85

33514 2119.14 2119.14

33516 2221.42 2221.42

33517 151.47 151.47

33518 332.71 332.71

33519 439.98 439.98

33521 527.83 527.83

33522 592.23 592.23

33523 670.97 670.97

33530 425.01 425.01

33533 1509.27 1509.27

33534 1775.88 1775.88

33535 1982.18 1982.18

33536 2136.19 2136.19

33542 2119.64 2119.64

33545 2502.79 2502.79

33548 2396.32 2396.32

33572 185.90 185.90

33600 1395.72 1395.72

33602 1354.81 1354.81

33606 1444.06 1444.06

33608 1461.90 1461.90

33610 1442.21 1442.21

CODE NOTE NFAC FAC 26 TC

33611 1586.12 1586.12

33612 1628.43 1628.43

33615 1622.00 1622.00

33617 1757.21 1757.21

33619 2214.78 2214.78

33620 1450.45 1450.45

33621 768.75 768.75

33622 3014.24 3014.24

33641 1332.63 1332.63

33645 1406.41 1406.41

33647 1477.30 1477.30

33660 1427.47 1427.47

33665 1598.26 1598.26

33670 1603.87 1603.87

33675 1603.11 1603.11

33676 1738.34 1738.34

33677 1806.04 1806.04

33681 1493.92 1493.92

33684 1535.49 1535.49

33688 1620.89 1620.89

33690 974.67 974.67

33692 1684.15 1684.15

33694 1586.12 1586.12

33697 1670.70 1670.70

33702 1255.78 1255.78

33710 1667.62 1667.62

33720 1256.59 1256.59

33722 1320.75 1320.75

33724 1251.09 1251.09

33726 1652.94 1652.94

33730 1629.16 1629.16

33732 1338.67 1338.67

33735 1052.60 1052.60

33736 1142.48 1142.48

33737 1054.02 1054.02

33750 1075.94 1075.94

33755 1117.44 1117.44

33762 1092.93 1092.93

33764 1069.56 1069.56

33766 1137.01 1137.01

33767 1155.76 1155.76

33768 361.21 361.21

33770 1821.67 1821.67

Maryland Medical Assistance FS-40

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

33771 1878.21 1878.21

33774 1461.79 1461.79

33775 1583.35 1583.35

33776 1673.04 1673.04

33777 1536.83 1536.83

33778 1908.81 1908.81

33779 2003.50 2003.50

33780 2039.30 2039.30

33781 1994.10 1994.10

33782 2624.39 2624.39

33783 2835.58 2835.58

33786 1956.45 1956.45

33788 1310.59 1310.59

33800 802.57 802.57

33802 880.69 880.69

33803 934.25 934.25

33813 1052.89 1052.89

33814 1237.36 1237.36

33820 787.50 787.50

33822 869.10 869.10

33824 957.99 957.99

33840 1051.75 1051.75

33845 1083.48 1083.48

33851 1081.05 1081.05

33852 1136.44 1136.44

33853 1488.94 1488.94

33860 2595.61 2595.61

33863 2546.21 2546.21

33864 2609.28 2609.28

33870 2042.84 2042.84

33875 2215.83 2215.83

33877 2942.45 2942.45

33880 1459.11 1459.11

33881 1253.63 1253.63

33883 910.06 910.06

33884 334.60 334.60

33886 783.58 783.58

33889 638.92 638.92

33891 794.55 794.55

33910 2130.63 2130.63

33915 1025.74 1025.74

33916 3397.35 3397.35

33917 1183.97 1183.97

CODE NOTE NFAC FAC 26 TC

33920 1550.54 1550.54

33922 1128.35 1128.35

33924 232.36 232.36

33925 1396.43 1396.43

33926 2080.65 2080.65

33927 2277.89 2277.89

33928 REPORT REPORT REPORT

33929 REPORT REPORT REPORT

33930 N.C. N.C.

33933 P 404.28 404.28

33935 P 4021.77 4021.77

33940 N.C. N.C.

33944 P 385.99 385.99

33945 P 3930.74 3930.74

33946 276.14 276.14

33947 300.41 300.41

33948 210.03 210.03

33949 205.00 205.00

33951 343.72 343.72

33952 346.37 346.37

33953 383.99 383.99

33954 387.09 387.09

33955 783.46 780.64

33956 739.44 736.33

33957 186.15 186.15

33958 181.78 181.78

33959 235.82 235.82

33962 237.60 237.60

33963 495.97 493.14

33964 501.16 498.95

33965 186.15 186.15

33966 238.82 238.82

33967 210.34 210.34

33968 27.19 27.19

33969 305.34 302.84

33970 287.56 287.56

33971 574.83 574.83

33973 417.17 417.17

33974 723.20 723.20

33975 1060.93 1060.93

33976 1293.32 1293.32

33977 913.08 913.08

33978 1081.78 1081.78

Maryland Medical Assistance FS-41

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

33979 1756.56 1756.56

33980 1795.70 1795.70

33981 670.83 670.83

33982 1586.34 1586.34

33983 1876.67 1876.67

33984 298.28 295.15

33985 563.76 560.94

33986 536.67 533.56

33987 226.86 226.86

33988 644.96 641.54

33989 433.37 430.25

33990 345.39 345.39

33991 505.50 505.50

33992 162.47 162.47

33993 141.86 141.86

33999 REPORT REPORT REPORT

34001 788.60 788.60

34051 722.65 722.65

34101 488.72 488.72

34111 488.36 488.36

34151 1142.48 1142.48

34201 840.30 840.30

34203 778.13 778.13

34401 1186.37 1186.37

34421 590.78 590.78

34451 1330.16 1330.16

34471 885.25 885.25

34490 496.00 496.00

34501 728.77 728.77

34502 1248.22 1248.22

34510 973.81 973.81

34520 856.87 856.87

34530 774.24 774.24

34701 1098.66 1098.66

34702 1639.54 1639.54

34703 1240.79 1240.79

34704 2061.02 2061.02

34705 1364.08 1364.08

34706 2052.61 2052.61

34707 1024.37 1024.37

34708 1647.32 1647.32

34709 288.52 288.52

34710 715.86 715.86

CODE NOTE NFAC FAC 26 TC

34711 266.41 266.41

34712 611.59 611.59

34713 114.97 114.97

34714 241.08 241.08

34715 268.88 268.88

34716 334.47 334.47

34808 169.05 169.05

34812 274.52 274.52

34813 192.16 192.16

34820 398.17 398.17

34830 1466.29 1466.29

34831 1550.38 1550.38

34832 1538.12 1538.12

34833 494.95 494.95

34834 221.52 221.52

34839 REPORT REPORT REPORT

34841 1562.88 1562.88

34842 1719.55 1719.55

34843 1876.21 1876.21

34844 2032.88 2032.88

34845 1562.88 1562.88

34846 1719.55 1719.55

34847 1876.21 1876.21

34848 2032.88 2032.88

35001 909.07 909.07

35002 931.10 931.10

35005 918.87 918.87

35011 820.58 820.58

35013 1021.87 1021.87

35021 1006.93 1006.93

35022 1160.58 1160.58

35045 805.20 805.20

35081 1421.46 1421.46

35082 1789.70 1789.70

35091 1460.05 1460.05

35092 2122.38 2122.38

35102 1535.83 1535.83

35103 1833.98 1833.98

35111 1079.49 1079.49

35112 1541.65 1541.65

35121 1346.29 1346.29

35122 1763.25 1763.25

35131 1133.09 1133.09

Maryland Medical Assistance FS-42

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

35132 1330.24 1330.24

35141 902.01 902.01

35142 1079.04 1079.04

35151 1012.15 1012.15

35152 1131.72 1131.72

35180 775.19 775.19

35182 1450.68 1450.68

35184 915.77 915.77

35188 867.67 867.67

35189 1294.38 1294.38

35190 620.41 620.41

35201 768.99 768.99

35206 633.37 633.37

35207 608.01 608.01

35211 1114.93 1114.93

35216 1658.87 1658.87

35221 1187.08 1187.08

35226 679.28 679.28

35231 1000.42 1000.42

35236 801.02 801.02

35241 1109.61 1109.61

35246 1276.00 1276.00

35251 1393.93 1393.93

35256 830.29 830.29

35261 867.01 867.01

35266 707.01 707.01

35271 1122.66 1122.66

35276 1186.82 1186.82

35281 1314.89 1314.89

35286 760.82 760.82

35301 923.89 923.89

35302 917.18 917.18

35303 1011.77 1011.77

35304 1049.98 1049.98

35305 1003.68 1003.68

35306 361.78 361.78

35311 1266.20 1266.20

35321 726.50 726.50

35331 1183.30 1183.30

35341 1117.38 1117.38

35351 1042.84 1042.84

35355 843.22 843.22

35361 1240.91 1240.91

CODE NOTE NFAC FAC 26 TC

35363 1440.43 1440.43

35371 668.18 668.18

35372 800.37 800.37

35390 129.99 129.99

35400 121.41 121.41

35500 259.98 259.98

35501 1221.68 1221.68

35506 1039.25 1039.25

35508 1089.71 1089.71

35509 1149.95 1149.95

35510 999.85 999.85

35511 994.75 994.75

35512 1122.18 1122.18

35515 1172.00 1172.00

35516 992.43 992.43

35518 945.40 945.40

35521 997.93 997.93

35522 986.78 986.78

35523 1043.97 1043.97

35525 936.96 936.96

35526 1376.01 1376.01

35531 1653.46 1653.46

35533 1219.26 1219.26

35535 N.C. N.C.

35536 1396.43 1396.43

35537 1940.81 1940.81

35538 1915.47 1915.47

35539 1816.33 1816.33

35540 2088.16 2088.16

35556 1142.87 1142.87

35558 1005.55 1005.55

35560 1391.45 1391.45

35563 1223.73 1223.73

35565 1086.79 1086.79

35566 1363.55 1363.55

35570 N.C. N.C.

35571 1083.49 1083.49

35572 281.88 281.88

35583 1181.76 1181.76

35585 1369.93 1369.93

35587 1117.87 1117.87

35600 206.41 206.41

35601 1142.66 1142.66

Maryland Medical Assistance FS-43

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

35606 958.18 958.18

35612 868.32 868.32

35616 901.45 901.45

35621 897.33 897.33

35623 1077.26 1077.26

35626 1282.98 1282.98

35631 1511.87 1511.87

35632 1470.50 1470.50

35633 1635.41 1635.41

35634 1468.08 1468.08

35636 1323.61 1323.61

35637 1416.79 1416.79

35638 1439.95 1439.95

35642 896.63 896.63

35645 852.08 852.08

35646 1401.38 1401.38

35647 1269.12 1269.12

35650 888.84 888.84

35654 1119.24 1119.24

35656 885.34 885.34

35661 887.20 887.20

35663 1019.87 1019.87

35665 957.24 957.24

35666 1033.29 1033.29

35671 911.13 911.13

35681 65.59 65.59

35682 287.93 287.93

35683 332.35 332.35

35685 161.89 161.89

35686 130.38 130.38

35691 764.82 764.82

35693 679.96 679.96

35694 805.52 805.52

35695 850.09 850.09

35697 120.23 120.23

35700 124.42 124.42

35701 458.25 458.25

35721 373.73 373.73

35741 417.54 417.54

35761 318.06 318.06

35800 580.41 580.41

35820 1627.74 1627.74

35840 966.15 966.15

CODE NOTE NFAC FAC 26 TC

35860 684.18 684.18

35870 1013.79 1013.79

35875 486.48 486.48

35876 772.86 772.86

35879 752.46 752.46

35881 832.20 832.20

35883 986.00 986.00

35884 1009.06 1009.06

35901 404.09 404.09

35903 459.98 459.98

35905 1443.19 1443.19

35907 1559.37 1559.37

36000 20.54 7.43

36002 129.47

36005 265.09 38.65

36010 518.88 93.19

36011 792.31 126.06

36012 684.38 139.13

36013 667.55 98.40

36014 662.49 120.90

36015 721.93 136.73

36100 429.52 124.09

36140 400.71 77.42

36160 442.72 102.27

36200 531.38 116.43

36215 912.87 187.78

36216 990.58 218.82

36217 1678.00 260.26

36218 158.97 41.79

36221 1011.41 184.18

36222 1251.70 248.84

36223 1369.44 268.96

36224 1514.70 297.18

36225 1359.31 262.89

36226 1516.38 293.27

36227 216.59 94.22

36228 1041.05 193.01

36245 1045.79 193.05

36246 818.87 206.68

36247 1579.97 246.16

36248 134.56 39.35

36251 1275.20 239.23

36252 1398.25 311.53

Maryland Medical Assistance FS-44

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

36253 1951.72 332.77

36254 2030.17 358.93

36260 517.00 517.00

36261 261.96 261.96

36262 242.38 242.38

36299 REPORT REPORT REPORT

36400 21.38 14.25

36405 20.37 12.96

36406 14.84

36410 13.73 7.43

36415 2.39 2.39

36420 43.14 43.14

36425 31.99 31.99

36430 30.57 30.57

36440 43.31 43.31

36450 148.93 148.93

36455 102.90 102.90

36456 93.52 93.52

36460 273.91 273.91

36465 1411.90 112.95

36466 1474.55 132.71

36468 P REPORT REPORT REPORT

36470 129.55 73.57

36471 139.63 80.64

36473 1321.47 151.70

36474 240.46 75.99

36475 1475.62 253.22

36476 297.82 123.15

36478 1276.11 255.60

36479 302.87 125.02

36481 1574.77 268.50

36482 1878.99 150.32

36483 126.20 78.24

36500 146.57 146.57

36510 85.51 45.07

36511 73.84 73.84

36512 74.66 74.66

36513 77.42 77.42

36514 454.52 74.00

36516 2023.07 56.44

36522 1145.03 81.30

36555 211.96 93.90

36556 193.62 95.51

CODE NOTE NFAC FAC 26 TC

36557 738.91 253.52

36558 670.08 217.44

36560 931.00 272.22

36561 937.61 273.41

36563 989.81 298.33

36565 794.08 270.15

36566 4366.86 301.31

36568 250.25 71.12

36569 226.44 72.66

36570 993.67 254.88

36571 1008.54 249.82

36575 133.30 30.93

36576 276.60 148.59

36578 394.99 163.25

36580 200.06

36581 612.45 151.58

36582 843.16 234.48

36583 1005.20 262.16

36584 198.12 54.68

36585 875.27 219.87

36589 130.52 110.00

36590 198.92 153.80

36591 19.13 19.13

36592 21.41 21.41

36593 28.28 28.28

36595 513.36 146.20

36596 113.22

36597 101.04 48.59

36598 92.10 36.46

36600 24.83 12.01 24.83

36620 40.08 40.08

36625 83.32 83.32

36640 90.94 90.94

36660 58.75 58.75

36680 46.56 46.56

36800 117.09 117.09

36810 173.48 173.48

36815 111.21 111.21

36818 566.19 566.19

36819 597.75 597.75

36820 597.41 597.41

36821 541.88 541.88

36823 1123.33 1123.33

Maryland Medical Assistance FS-45

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

36825 652.18 652.18

36830 544.88 544.88

36831 503.52 503.52

36832 617.74 617.74

36833 662.89 662.89

36835 399.96 399.96

36838 933.72 933.72

36860 166.43 88.06

36861 110.38 110.38

36901 501.99 127.66

36902 1070.02 190.04

36903 4926.19 260.10

36904 1559.32 299.39

36905 1995.62 375.78

36906 5969.69 438.77

36907 640.36 109.37

36908 2366.30 163.98

36909 1724.99 155.77

37140 1872.40 1872.40

37145 1740.97 1740.97

37160 1788.70 1788.70

37180 1721.29 1721.29

37181 1725.43 1725.43

37182 659.81 659.81

37183 4680.01 302.33

37184 2042.85 365.26

37185 672.51 136.52

37186 1387.09 200.02

37187 1977.99 317.67

37188 1704.82 228.96

37191 2324.25 203.37

37192 1552.75 314.59

37193 1481.51 314.38

37195 102.73 102.73

37197 1371.60 257.45

37200 174.40 174.40

37211 343.53 343.53

37212 303.30 303.30

37213 211.78 211.78

37214 124.70 124.70

37215 810.59 810.59

37216 714.29 714.29

37217 935.54 935.54

CODE NOTE NFAC FAC 26 TC

37218 706.56 759.62

37220 2688.71 360.02

37221 3975.29 437.68

37222 773.43 163.43

37223 2191.09 185.59

37224 3231.24 396.47

37225 9150.99 535.33

37226 7649.07 437.53

37227 12360.24 645.20

37228 4602.12 484.60

37229 9060.12 626.05

37230 7113.94 602.55

37231 11424.49 655.77

37232 1031.65 174.86

37233 1258.76 288.13

37234 3294.53 239.84

37235 3517.20 340.46

37236 3179.68 377.11

37237 1944.32 184.32

37238 3457.89 276.63

37239 1719.03 122.57

37241 3823.59 382.36

37242 6448.75 386.93

37243 8141.92 488.52

37244 5691.56 569.16

37246 1885.28 312.01

37247 761.90 154.59

37248 1304.41 268.45

37249 558.44 131.62

37252 1237.63 81.56

37253 190.55 65.24

37500 525.64 525.64

37501 REPORT REPORT REPORT

37565 592.43 592.43

37600 573.51 573.51

37605 640.42 640.42

37606 420.72 420.72

37607 305.79 305.79

37609 248.45 167.23

37615 409.20 409.20

37616 891.44 891.44

37617 1085.21 1085.21

37618 311.04 311.04

Maryland Medical Assistance FS-46

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

37619 1411.82 1411.82

37650 375.60 375.60

37660 1053.05 1053.05

37700 202.03 202.03

37718 352.78 352.78

37722 387.70 387.70

37735 474.24 474.24

37760 498.76 498.76

37761 446.55 446.55

37765 523.60 364.27

37766 621.10 444.40

37780 204.24 204.24

37785 286.54 213.30

37788 1005.79 1005.79

37790 388.73 388.73

37799 REPORT REPORT REPORT

38100 932.10 932.10

38101 933.02 933.02

38102 212.08 212.08

38115 1024.29 1024.29

38120 850.80 850.80

38129 REPORT REPORT REPORT

38200 107.52 107.52

38204 P 65.00 83.84

38205 P 65.92 65.92

38206 P 65.92 65.92

38207 P 34.19 37.23

38208 P 21.82 23.75

38209 P 9.47 9.91

38210 P 60.89 65.63

38211 P 54.86 59.57

38212 P 36.47 39.45

38213 P 9.47 9.91

38214 P 31.02 33.93

38215 P 36.47 39.45

38220 134.46 49.24

38221 136.13 59.01

38222 149.29 67.18

38230 196.43 196.43

38232 157.99 157.99

38240 P 177.48 177.48

38241 P 132.67 132.67

38242 P 93.95 93.95

CODE NOTE NFAC FAC 26 TC

38243 97.80 97.80

38300 217.82 146.29

38305 369.09 369.09

38308 360.14 360.14

38380 449.40 449.40

38381 649.49 649.49

38382 542.29 542.29

38500 266.49 205.22

38505 100.56 56.95

38510 415.82 337.44

38520 373.50 373.50

38525 353.17 353.17

38530 446.59 446.59

38542 415.78 415.78

38550 407.90 407.90

38555 820.56 820.56

38562 567.59 567.59

38564 564.52 564.52

38570 404.67 404.67

38571 582.35 582.35

38572 756.48 756.48

38573 1031.31 1031.31

38589 REPORT REPORT REPORT

38700 643.87 643.87

38720 1075.25 1075.25

38724 1160.23 1160.23

38740 561.09 561.09

38745 708.54 708.54

38746 194.16 194.16

38747 215.76 215.76

38760 679.98 679.98

38765 1043.53 1043.53

38770 647.47 647.47

38780 822.94 822.94

38790 66.76 66.76

38792 32.05 32.05

38794 239.53 239.53

38900 113.41 113.41

38999 REPORT REPORT REPORT

39000 400.75 400.75

39010 635.91 635.91

39200 703.68 703.68

39220 915.39 915.39

Maryland Medical Assistance FS-47

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

39401 276.01 276.01

39402 359.77 359.77

39499 REPORT REPORT REPORT

39501 684.98 684.98

39503 4782.77 4782.77

39540 701.56 701.56

39541 762.63 762.63

39545 715.80 715.80

39560 644.81 644.81

39561 1004.63 1004.63

39599 REPORT REPORT REPORT

40490 103.48 59.02

40500 407.91 293.90

40510 389.83 287.50

40520 394.16 289.00

40525 443.88 443.88

40527 500.64 500.64

40530 431.94 323.65

40650 353.47 240.89

40652 396.29 285.73

40654 461.16 344.58

40700 814.20 814.20

40701 964.23 964.23

40702 723.39 723.39

40720 802.83 802.83

40761 777.78 777.78

40799 REPORT REPORT REPORT

40800 173.97 108.12

40801 256.85 182.18

40804 149.54 93.16

40805 262.36 190.53

40806 85.71 26.99

40808 152.30 88.73

40810 168.35 104.23

40812 235.78 161.67

40814 314.96 249.98

40816 327.95 258.69

40818 293.51 223.39

40819 258.39 196.84

40820 217.41 141.88

40830 218.68 135.73

40831 275.34 184.15

40840 654.02 506.67

CODE NOTE NFAC FAC 26 TC

40842 662.12 526.78

40843 878.03 692.24

40844 1038.76 843.78

40845 1175.04 986.09

40899 REPORT REPORT REPORT

41000 131.88 91.42

41005 184.90 101.68

41006 315.51 220.60

41007 311.11 213.92

41008 310.48 221.28

41009 329.53 240.33

41010 162.93 87.13

41015 371.27 287.47

41016 359.95 288.10

41017 364.50 290.11

41018 412.77 337.81

41019 374.49 374.49

41100 136.31 87.29

41105 138.86 90.97

41108 120.52 73.79

41110 172.32 106.75

41112 273.04 207.21

41113 298.64 229.09

41114 515.31 515.31

41115 199.92 117.55

41116 269.99 179.65

41120 878.43 878.43

41130 1078.20 1078.20

41135 1767.85 1767.85

41140 1782.68 1782.68

41145 2251.54 2251.54

41150 1790.31 1790.31

41153 1945.04 1945.04

41155 2448.83 2448.83

41250 217.02 124.40

41251 232.95 147.18

41252 257.07 171.29

41500 367.34 367.34

41510 346.53 346.53

41512 536.96 536.96

41520 287.69 210.73

41530 989.15 305.25

41599 REPORT REPORT REPORT

Maryland Medical Assistance FS-48

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

41800 225.65 121.06

41805 202.09 140.23

41806 289.15 212.76

41820 49.00 49.00

41821 18.00 18.00

41822 256.87 151.42

41823 374.84 273.93

41825 173.45 99.92

41826 258.54 175.03

41827 361.26 252.67

41828 251.12 175.03

41830 321.61 232.68

41850 26.00 26.00

41870 50.00 50.00

41872 307.54 215.49

41874 310.59 211.14

41899 REPORT REPORT REPORT

42000 129.66 84.63

42100 121.89 88.83

42104 175.32 113.19

42106 223.80 146.28

42107 374.71 281.22

42120 824.63 824.63

42140 204.62 125.08

42145 565.79 565.79

42160 188.48 119.23

42180 196.29 147.53

42182 257.46 205.61

42200 685.05 685.05

42205 732.90 732.90

42210 837.11 837.11

42215 585.98 585.98

42220 425.67 425.67

42225 729.65 729.65

42226 733.45 733.45

42227 697.59 697.59

42235 589.85 589.85

42260 677.27 561.86

42280 133.07 90.04

42281 165.19 121.58

42299 REPORT REPORT REPORT

42300 168.61 123.00

42305 347.51 347.51

CODE NOTE NFAC FAC 26 TC

42310 129.75 99.83

42320 199.92 140.34

42330 187.32 132.88

42335 302.05 207.72

42340 375.47 271.43

42400 84.92 44.17

42405 240.30 181.86

42408 365.86 262.94

42409 269.07 179.01

42410 498.44 498.44

42415 844.60 844.60

42420 947.38 947.38

42425 668.72 668.72

42426 1079.27 1079.27

42440 333.88 333.88

42450 364.89 288.77

42500 349.99 275.90

42505 446.53 363.88

42507 404.48 404.48

42509 677.93 677.93

42510 519.78 519.78

42550 119.63 50.18

42600 379.26 275.49

42650 67.34 47.40

42660 104.57 73.21

42665 255.24 167.74

42699 REPORT REPORT REPORT

42700 152.76 109.15

42720 363.33 313.74

42725 659.27 659.27

42800 127.73 90.10

42804 157.86 91.16

42806 177.06 106.09

42808 182.62 130.17

42809 161.64 98.07

42810 312.04 232.81

42815 449.56 449.56

42820 231.34 231.34

42821 241.44 241.44

42825 210.41 210.41

42826 201.93 201.93

42830 166.53 166.53

42831 179.98 179.98

Maryland Medical Assistance FS-49

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

42835 146.05 146.05

42836 193.35 193.35

42842 822.97 822.97

42844 1130.83 1130.83

42845 1810.01 1810.01

42860 151.33 151.33

42870 485.76 485.76

42890 1164.63 1164.63

42892 1536.51 1536.51

42894 1928.13 1928.13

42900 270.90 270.90

42950 666.21 666.21

42953 801.10 801.10

42955 620.21 620.21

42960 136.72 136.72

42961 339.26 339.26

42962 417.46 417.46

42970 328.22 328.22

42971 369.66 369.66

42972 409.76 409.76

42999 REPORT REPORT REPORT

43020 429.43 429.43

43030 415.19 415.19

43045 1052.03 1052.03

43100 497.68 497.68

43101 863.25 863.25

43107 2068.49 2068.49

43108 3772.57 3772.57

43112 2184.63 2184.63

43113 3526.95 3526.95

43116 4212.72 4212.72

43117 1995.86 1995.86

43118 3063.07 3063.07

43121 2307.04 2307.04

43122 2072.92 2072.92

43123 3805.66 3805.66

43124 3103.99 3103.99

43130 630.07 630.07

43135 1198.13 1198.13

43180 460.23 508.00

43191 124.04 124.04

43192 136.37 136.37

43193 148.40 148.40

CODE NOTE NFAC FAC 26 TC

43194 155.37 155.37

43195 148.70 148.70

43196 163.21 163.21

43197 152.99 66.69

43198 170.59 79.67

43200 173.40 76.54

43201 208.86 94.07

43202 246.23 84.04

43204 137.13 137.13

43205 142.58 142.58

43206 N.C. N.C.

43210 374.47 374.47

43211 202.78 202.78

43212 160.14 160.14

43213 1030.18 226.64

43214 163.21 163.21

43215 288.38 115.38

43216 285.17 109.33

43217 303.77 130.77

43220 863.72 95.87

43226 254.09 106.16

43227 503.85 150.90

43229 606.36 169.78

43231 267.31 136.70

43232 320.51 190.74

43233 193.60 193.60

43235 229.40 103.80

43236 285.04 125.96

43237 173.65 173.65

43238 212.76 212.76

43239 273.96 123.20

43240 319.06 319.06

43241 115.99 115.99

43242 265.20 265.20

43243 192.62 192.62

43244 212.82 212.82

43245 442.47 142.92

43246 180.44 180.44

43247 278.99 144.41

43248 279.47 135.82

43249 817.67 125.10

43250 317.56 138.58

43251 351.38 159.28

Maryland Medical Assistance FS-50

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

43252 N.C. N.C.

43253 224.65 224.65

43254 233.30 233.30

43255 532.48 203.25

43257 219.93 219.93

43259 216.98 216.98

43260 261.78 261.78

43261 275.04 275.04

43262 307.74 307.74

43263 303.23 303.23

43264 369.24 369.24

43265 414.62 414.62

43266 204.96 204.96

43270 603.43 205.17

43273 98.38 98.38

43274 399.37 399.37

43275 329.39 329.39

43276 415.39 415.39

43277 331.38 331.38

43278 376.70 376.70

43279 1043.91 1043.91

43280 874.24 874.24

43281 1248.73 1248.73

43282 1404.47 1404.47

43283 135.59 135.59

43284 576.20 576.20

43285 582.70 582.70

43286 2801.83 2801.83

43287 3202.94 3202.94

43288 3336.54 3336.54

43289 REPORT REPORT REPORT

43300 496.71 496.71

43305 873.05 873.05

43310 1191.99 1191.99

43312 1298.64 1298.64

43313 2172.21 2172.21

43314 2402.63 2402.63

43320 1120.42 1120.42

43325 1079.94 1079.94

43327 684.75 684.75

43328 1006.71 1006.71

43330 1080.96 1080.96

43331 1081.89 1081.89

CODE NOTE NFAC FAC 26 TC

43332 980.12 980.12

43333 1025.20 1025.20

43334 1075.02 1075.02

43335 1158.04 1158.04

43336 1270.11 1270.11

43337 1387.08 1387.08

43338 112.99 112.99

43340 1107.09 1107.09

43341 1136.31 1136.31

43351 1116.01 1116.01

43352 866.59 866.59

43360 1911.14 1911.14

43361 2083.92 2083.92

43400 1193.46 1193.46

43401 1181.40 1181.40

43405 1237.52 1237.52

43410 851.35 851.35

43415 2078.33 2078.33

43420 814.90 814.90

43425 1178.70 1178.70

43450 125.31 64.61

43453 732.47 69.80

43460 173.03 173.03

43496 1588.64 1588.64

43499 REPORT REPORT REPORT

43500 635.05 635.05

43501 1088.58 1088.58

43502 1217.00 1217.00

43510 748.50 748.50

43520 555.14 555.14

43605 679.79 679.79

43610 791.85 791.85

43611 988.48 988.48

43620 1590.27 1590.27

43621 1834.43 1834.43

43622 1853.82 1853.82

43631 1172.58 1172.58

43632 1642.99 1642.99

43633 1553.88 1553.88

43634 1713.86 1713.86

43635 91.39 91.39

43640 953.10 953.10

43641 963.94 963.94

Maryland Medical Assistance FS-51

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

43644 P 1401.18 1401.18

43645 P 1492.65 1492.65

43647 546.30 546.30

43648 400.39 178.85

43651 528.17 528.17

43652 619.10 619.10

43653 463.59 463.59

43659 REPORT REPORT REPORT

43752 32.39 32.39

43753 17.33 17.33

43754 98.59 28.48

43755 110.49 48.36

43756 184.44 43.01

43757 236.86 62.34

43760 394.94 37.91

43761 92.76 81.93

43770 P 905.86 905.86

43771 P 1028.04 1028.04

43772 P 765.17 765.17

43773 P 1030.65 1030.65

43774 P 775.16 775.16

43775 P 969.41 969.41

43800 751.83 751.83

43810 820.02 820.02

43820 1084.54 1084.54

43825 1044.32 1044.32

43830 564.90 564.90

43831 453.84 453.84

43832 837.57 837.57

43840 1098.44 1098.44

43842 P 834.21 952.75

43843 P 1026.90 1026.90

43845 P 1586.00 1586.00

43846 P 1308.71 1308.71

43847 P 1433.37 1433.37

43848 P 1554.64 1554.64

43850 1304.02 1304.02

43855 1343.87 1343.87

43860 1321.84 1321.84

43865 1368.10 1368.10

43870 574.48 574.48

43880 1292.89 1292.89

43881 520.39 477.09

CODE NOTE NFAC FAC 26 TC

43882 552.95 506.34

43886 293.41 293.41

43887 264.41 264.41

43888 370.63 370.63

43999 REPORT REPORT REPORT

44005 885.04 885.04

44010 696.57 696.57

44015 115.31 115.31

44020 786.51 786.51

44021 786.62 786.62

44025 793.78 793.78

44050 755.33 755.33

44055 1204.46 1204.46

44100 87.57 87.57

44110 688.39 688.39

44111 791.82 791.82

44120 988.75 988.75

44121 195.95 195.95

44125 953.73 953.73

44126 1967.04 1967.04

44127 2232.37 2232.37

44128 198.19 198.19

44130 1061.22 1061.22

44132 P REPORT REPORT REPORT

44133 P REPORT REPORT REPORT

44135 P 4000.00 4000.00

44136 P REPORT REPORT REPORT

44137 1223.69 1223.69

44139 98.22 98.22

44140 1084.16 1084.16

44141 1477.12 1477.12

44143 1346.27 1346.27

44144 1430.27 1430.27

44145 1338.94 1338.94

44146 1714.41 1714.41

44147 1569.32 1569.32

44150 1511.54 1511.54

44151 1725.86 1725.86

44155 1683.02 1683.02

44156 1834.88 1834.88

44157 1743.62 1743.62

44158 1808.46 1808.46

44160 1003.35 1003.35

Maryland Medical Assistance FS-52

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

44180 742.78 742.78

44186 526.88 526.88

44187 892.40 892.40

44188 990.35 990.35

44202 1120.00 1120.00

44203 194.91 194.91

44204 1242.33 1242.33

44205 1080.34 1080.34

44206 1414.96 1414.96

44207 1468.20 1468.20

44208 1603.69 1603.69

44210 1436.42 1436.42

44211 1762.07 1762.07

44212 1649.91 1649.91

44213 152.17 152.17

44227 1346.90 1346.90

44238 REPORT REPORT REPORT

44300 680.29 680.29

44310 842.83 842.83

44312 475.87 475.87

44314 808.91 808.91

44316 1147.19 1147.19

44320 970.87 970.87

44322 807.33 807.33

44340 504.08 504.08

44345 849.66 849.66

44346 955.52 955.52

44360 117.02 117.02

44361 129.14 129.14

44363 156.01 156.01

44364 166.10 166.10

44365 146.30 146.30

44366 195.05 195.05

44369 200.05 200.05

44370 216.91 216.91

44372 195.59 195.59

44373 156.40 156.40

44376 231.01 231.01

44377 243.43 243.43

44378 312.56 312.56

44379 333.27 333.27

44380 134.70 49.52

44381 754.22 69.09

CODE NOTE NFAC FAC 26 TC

44382 210.10 59.61

44384 123.49 123.49

44385 172.31 76.80

44386 266.98 90.21

44388 245.99 127.25

44389 302.56 139.84

44390 339.74 171.36

44391 554.55 187.16

44392 323.45 161.14

44394 378.39 183.94

44401 2561.78 197.00

44402 211.44 211.44

44403 246.49 246.49

44404 287.35 139.71

44405 431.56 148.85

44406 186.67 186.67

44407 223.63 223.63

44408 188.30 188.30

44500 18.77 18.77

44602 1140.75 1140.75

44603 1310.09 1310.09

44604 855.09 855.09

44605 1052.89 1052.89

44615 867.33 867.33

44620 701.04 701.04

44625 820.31 820.31

44626 1295.06 1295.06

44640 1132.75 1132.75

44650 1167.92 1167.92

44660 1075.01 1075.01

44661 1250.10 1250.10

44680 862.63 862.63

44700 819.25 819.25

44701 135.96 135.96

44705 N.C. N.C.

44715 P 311.96 311.96

44720 P 244.99 244.99

44721 P 311.60 311.60

44799 REPORT REPORT REPORT

44800 618.48 618.48

44820 675.54 675.54

44850 605.90 605.90

44899 REPORT REPORT REPORT

Maryland Medical Assistance FS-53

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

44900 619.27 619.27

44950 518.84 518.84

44955 67.90 67.90

44960 706.72 706.72

44970 485.58 485.58

44979 REPORT REPORT REPORT

45000 340.86 340.86

45005 221.81 130.60

45020 462.17 462.17

45100 241.43 241.43

45108 294.76 294.76

45110 1489.52 1489.52

45111 876.81 876.81

45112 1510.65 1510.65

45113 1555.38 1555.38

45114 1459.24 1459.24

45116 1305.89 1305.89

45119 1566.68 1566.68

45120 1283.59 1283.59

45121 1333.31 1333.31

45123 901.51 901.51

45126 2244.09 2244.09

45130 875.88 875.88

45135 1104.94 1104.94

45136 1546.47 1546.47

45150 288.28 288.28

45160 825.91 825.91

45171 485.26 485.26

45172 652.03 652.03

45190 559.75 559.75

45300 99.00 43.71

45303 728.22 70.13

45305 120.76

45307 138.88 78.69

45308 128.36 68.22

45309 143.50 72.70

45315 148.49 85.40

45317 145.75 90.45

45320 142.85 84.61

45321 82.16 82.16

45327 91.41 91.41

45330 133.94 45.59

45331 205.60 58.53

CODE NOTE NFAC FAC 26 TC

45332 211.38 85.69

45333 235.36 78.37

45334 442.35 117.89

45335 187.54 65.58

45337 101.94 101.94

45338 234.80 101.39

45340 346.87 81.97

45341 112.18 112.18

45342 170.97 170.97

45346 2462.58 130.52

45347 125.56 125.56

45349 161.22 161.22

45350 421.48 82.02

45379 376.43 194.46

45380 356.70 186.45

45381 347.21 176.04

45382 576.22 237.58

45384 358.24 194.70

45385 400.29 221.04

45386 513.67 190.83

45388 2585.77 220.05

45389 235.79 235.79

45390 269.95 269.95

45391 214.84 214.84

45392 269.79 269.79

45393 205.36 205.36

45395 1593.69 1593.69

45397 1733.21 1733.21

45398 538.23 190.80

45399 REPORT REPORT REPORT

45400 917.19 917.19

45402 1222.91 1222.91

45499 REPORT REPORT REPORT

45500 419.19 419.19

45505 477.34 477.34

45520 125.19 32.56

45540 850.46 850.46

45541 761.34 761.34

45550 1177.21 1177.21

45560 549.67 549.67

45562 906.94 906.94

45563 1326.87 1326.87

45800 968.74 968.74

Maryland Medical Assistance FS-54

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

45805 1156.08 1156.08

45820 900.97 900.97

45825 1147.76 1147.76

45900 163.24 163.24

45905 135.96 135.96

45910 155.72 155.72

45915 265.95 182.15

45990 86.76 86.76

45999 REPORT REPORT REPORT

46020 222.14 188.80

46030 111.89 72.84

46040 430.87 334.27

46045 350.74 350.74

46050 162.38 78.58

46060 383.73 383.73

46070 182.22 182.22

46080 199.50 128.54

46083 141.78 85.64

46200 359.34 263.00

46220 165.64 95.52

46221 215.21 153.08

46230 219.39 138.74

46250 372.43 253.85

46255 407.23 284.98

46257 339.00 339.00

46258 374.55 374.55

46260 382.97 382.97

46261 419.75 419.75

46262 445.22 445.22

46270 408.80 315.88

46275 432.57 333.12

46280 377.42 377.42

46285 429.90 332.70

46288 442.74 442.74

46320 147.63 89.20

46500 150.92 99.34

46505 228.64 191.87

46600 71.11 32.92

46601 108.35 75.00

46604 502.01 53.66

46606 182.01 61.16

46607 153.22 101.63

46608 189.03 67.62

CODE NOTE NFAC FAC 26 TC

46610 183.50 65.78

46611 141.71 65.61

46612 200.62 74.09

46614 103.01 52.78

46615 114.75 74.77

46700 525.73 525.73

46705 400.90 400.90

46706 141.16 141.16

46707 379.89 379.89

46710 835.53 835.53

46712 1693.55 1693.55

46715 437.85 437.85

46716 886.97 886.97

46730 1456.92 1456.92

46735 1686.65 1686.65

46740 1627.48 1627.48

46742 2191.69 2191.69

46744 2851.29 2851.29

46746 2860.76 2860.76

46748 3168.46 3168.46

46750 604.02 604.02

46751 476.94 476.94

46753 463.25 463.25

46754 235.33 181.46

46760 887.16 887.16

46761 738.85 738.85

46762 731.12 731.12

46900 194.35 109.98

46910 206.18 107.28

46916 184.59 115.04

46917 366.71 106.20

46922 214.92 108.90

46924 429.30 147.12

46930 165.06 118.03

46940 183.02 117.19

46942 173.11 105.27

46945 248.99 182.58

46946 252.12 181.43

46947 307.87 307.87

46999 REPORT REPORT REPORT

47000 245.39 73.03

47001 84.42 84.42

47010 974.99 974.99

Maryland Medical Assistance FS-55

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

47015 940.02 940.02

47100 682.57 682.57

47120 1884.69 1884.69

47122 2772.00 2772.00

47125 2485.52 2485.52

47130 2670.22 2670.22

47133 N.C. N.C.

47135 P 4340.47 4340.47

47140 P 2678.22 2678.22

47141 P 3454.28 3454.28

47142 P 3787.40 3787.40

47143 P 312.82 312.82

47144 P 371.47 371.47

47145 P 351.91 351.91

47146 P 267.29 267.29

47147 P 309.99 309.99

47300 915.60 915.60

47350 1105.76 1105.76

47360 1495.73 1495.73

47361 2451.78 2451.78

47362 1174.02 1174.02

47370 1008.90 1008.90

47371 1001.49 1001.49

47379 REPORT REPORT REPORT

47380 1162.62 1162.62

47381 1106.06 1106.06

47382 3885.64 611.21

47383 6734.62 435.06

47399 REPORT REPORT REPORT

47400 1723.83 1723.83

47420 1083.70 1083.70

47425 1053.48 1053.48

47460 1017.19 1017.19

47480 709.01 709.01

47490 329.49 329.49

47531 326.57 70.41

47532 717.94 187.67

47533 1173.93 266.48

47534 1445.50 353.14

47535 971.16 203.17

47536 716.96 128.26

47537 354.17 87.02

47538 3973.22 234.82

CODE NOTE NFAC FAC 26 TC

47539 4339.58 385.79

47540 4510.00 460.92

47541 1035.68 267.41

47542 453.90 117.06

47543 575.09 148.14

47544 874.69 160.68

47550 133.98 133.98

47552 246.85 246.85

47553 244.59 244.59

47554 379.43 379.43

47555 290.22 290.22

47556 331.08 331.08

47562 531.59 531.59

47563 577.35 577.35

47564 899.84 899.84

47570 628.10 628.10

47579 REPORT REPORT REPORT

47600 862.58 862.58

47605 908.13 908.13

47610 1014.23 1014.23

47612 1024.16 1024.16

47620 1107.11 1107.11

47700 840.28 840.28

47701 1377.95 1377.95

47711 1258.41 1258.41

47712 1612.48 1612.48

47715 1072.02 1072.02

47720 922.65 922.65

47721 1092.88 1092.88

47740 1057.00 1057.00

47741 1172.37 1172.37

47760 1821.96 1821.96

47765 2458.92 2458.92

47780 2000.53 2000.53

47785 2621.35 2621.35

47800 1274.54 1274.54

47801 802.42 802.42

47802 1232.99 1232.99

47900 1109.62 1109.62

47999 REPORT REPORT REPORT

48000 1507.15 1507.15

48001 1871.13 1871.13

48020 938.08 938.08

Maryland Medical Assistance FS-56

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

48100 719.23 719.23

48102 424.99 192.44

48105 2302.12 2302.12

48120 894.65 894.65

48140 1264.33 1264.33

48145 1312.03 1312.03

48146 1514.99 1514.99

48148 1005.80 1005.80

48150 2519.72 2519.72

48152 2335.20 2335.20

48153 2504.48 2504.48

48154 2333.41 2333.41

48155 1470.66 1470.66

48160 P REPORT REPORT REPORT

48400 86.09 86.09

48500 912.46 912.46

48510 881.14 881.14

48520 882.33 882.33

48540 1060.50 1060.50

48545 1087.76 1087.76

48547 1441.69 1441.69

48548 1339.24 1339.24

48550 N.C. N.C.

48551 P 311.96 311.96

48552 P 189.58 189.58

48554 P 2065.67 2065.67

48556 1025.74 1025.74

48999 REPORT REPORT REPORT

49000 621.87 621.87

49002 844.29 844.29

49010 753.61 753.61

49020 1285.23 1285.23

49040 806.60 806.60

49060 886.08 886.08

49062 596.59 596.59

49082 154.43 59.52

49083 266.58 90.53

49084 87.57 87.57

49180 134.08 67.95

49185 877.70 107.17

49203 966.41 966.41

49204 1237.29 1237.29

49205 1421.25 1421.25

CODE NOTE NFAC FAC 26 TC

49215 1790.60 1790.60

49220 786.16 786.16

49250 475.56 475.56

49255 638.63 638.63

49320 262.28 262.28

49321 278.08 278.08

49322 296.98 296.98

49323 512.78 512.78

49324 314.17 314.17

49325 335.04 335.04

49326 152.85 152.85

49327 109.19 109.19

49329 REPORT REPORT REPORT

49400 139.03 74.20

49402 691.12 691.12

49405 726.78 174.43

49406 726.48 174.36

49407 612.43 189.85

49411 391.62 151.13

49412 68.19 68.19

49418 1286.94 193.68

49419 358.33 358.33

49421 230.51 230.51

49422 306.78 306.78

49423 461.95 57.24

49424 126.27 30.44

49425 579.48 579.48

49426 492.09 492.09

49427 36.66 36.66

49428 373.39 373.39

49429 371.88 371.88

49435 96.59 96.59

49436 150.86 150.86

49440 863.77 171.46

49441 1023.77 194.11

49442 834.35 167.12

49446 854.78 121.38

49450 600.97 53.19

49451 635.69 72.15

49452 776.18 110.92

49460 638.50 38.18

49465 132.18 24.66

49491 632.96 632.96

Maryland Medical Assistance FS-57

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

49492 773.97 773.97

49495 302.85 302.85

49496 432.57 432.57

49500 317.43 317.43

49501 489.63 489.63

49505 420.46 420.46

49507 472.57 472.57

49520 510.44 510.44

49521 578.72 578.72

49525 462.75 462.75

49540 543.84 543.84

49550 464.70 464.70

49553 509.35 509.35

49555 482.80 482.80

49557 585.17 585.17

49560 595.78 595.78

49561 751.03 751.03

49565 620.34 620.34

49566 757.66 757.66

49568 216.08 216.08

49570 336.59 336.59

49572 416.88 416.88

49580 264.72 264.72

49582 370.81 370.81

49585 359.42 359.42

49587 383.73 383.73

49590 462.52 462.52

49600 524.71 524.71

49605 3999.51 3999.51

49606 916.90 916.90

49610 521.77 521.77

49611 448.40 448.40

49650 345.99 345.99

49651 449.67 449.67

49652 600.70 600.70

49653 749.54 749.54

49654 683.20 683.20

49655 833.63 833.63

49656 741.05 741.05

49657 1067.01 1067.01

49659 REPORT REPORT REPORT

49900 657.92 657.92

49904 1145.66 1145.66

CODE NOTE NFAC FAC 26 TC

49905 285.14 285.14

49906 1535.01 1535.01

49999 REPORT REPORT REPORT

50010 593.22 593.22

50020 808.91 808.91

50040 737.66 737.66

50045 749.49 749.49

50060 908.38 908.38

50065 962.55 962.55

50070 989.84 989.84

50075 1161.71 1161.71

50080 692.50 692.50

50081 1016.08 1016.08

50100 884.47 884.47

50120 769.37 769.37

50125 820.75 820.75

50130 821.79 821.79

50135 893.03 893.03

50200 429.88 106.83

50205 607.97 607.97

50220 835.80 835.80

50225 957.91 957.91

50230 1021.48 1021.48

50234 1036.55 1036.55

50236 1168.58 1168.58

50240 1054.05 1054.05

50250 962.84 962.84

50280 764.99 764.99

50290 715.56 715.56

50300 P 219.00 219.00

50320 P 1216.10 1216.10

50323 P 457.74 457.74

50325 P 209.09 209.09

50327 P 175.25 175.25

50328 P 153.56 153.56

50329 P 144.67 144.67

50340 764.91 764.91

50360 P 1952.92 1952.92

50365 P 2306.31 2306.31

50370 970.45 970.45

50380 P 1551.30 1551.30

50382 1076.86 212.79

50384 866.23 193.43

Maryland Medical Assistance FS-58

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

50385 1030.22 178.85

50386 664.76 135.61

50387 512.17 76.88

50389 318.75 43.03

50390 76.42 76.42

50391 96.77 77.64

50395 141.85 141.85

50396 93.31 93.31

50400 922.71 922.71

50405 1113.36 1113.36

50430 455.85 144.96

50431 141.34 57.92

50432 740.27 191.29

50433 997.33 236.17

50434 789.83 181.19

50435 414.93 88.09

50500 922.92 922.92

50520 820.18 820.18

50525 1286.69 1286.69

50526 1186.48 1186.48

50540 906.25 906.25

50541 731.65 731.65

50542 928.42 928.42

50543 1184.47 1184.47

50544 992.14 992.14

50545 1066.99 1066.99

50546 959.19 959.19

50547 1296.98 1296.98

50548 1072.80 1072.80

50549 REPORT REPORT REPORT

50551 286.95 234.78

50553 305.67 249.24

50555 328.27 271.84

50557 334.45 276.02

50561 378.29 313.87

50562 462.81 462.81

50570 393.22 393.22

50572 423.80 423.80

50574 450.44 450.44

50575 569.52 569.52

50576 449.35 449.35

50580 484.27 484.27

50590 696.85 452.60

CODE NOTE NFAC FAC 26 TC

50592 1226.24 280.20

50593 3654.98 369.88

50600 750.49 750.49

50605 792.20 792.20

50606 564.64 136.64

50610 771.79 771.79

50620 718.34 718.34

50630 714.96 714.96

50650 824.94 824.94

50660 923.74 923.74

50684 105.84 40.46

50686 117.18 71.59

50688 63.40 63.40

50690 79.56 56.34

50693 929.70 189.47

50694 1022.26 244.83

50695 1245.84 309.96

50700 735.49 735.49

50705 1559.73 175.16

50706 801.67 162.18

50715 981.78 981.78

50722 840.30 840.30

50725 899.30 899.30

50727 406.77 406.77

50728 556.38 556.38

50740 979.47 979.47

50750 912.52 912.52

50760 899.25 899.25

50770 937.39 937.39

50780 884.06 884.06

50782 962.20 962.20

50783 902.45 902.45

50785 966.41 966.41

50800 736.00 736.00

50810 1100.62 1100.62

50815 976.57 976.57

50820 1047.89 1047.89

50825 1321.52 1321.52

50830 1449.39 1449.39

50840 980.59 980.59

50845 996.10 996.10

50860 759.40 759.40

50900 686.14 686.14

Maryland Medical Assistance FS-59

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

50920 731.24 731.24

50930 877.42 877.42

50940 702.56 702.56

50945 778.13 778.13

50947 1105.39 1105.39

50948 1016.35 1016.35

50949 REPORT REPORT REPORT

50951 299.72 244.42

50953 316.45 259.46

50955 353.07 280.94

50957 342.18 282.88

50961 308.55 252.98

50970 295.17 295.17

50972 285.27 285.27

50974 376.81 376.81

50976 371.57 371.57

50980 283.64 283.64

51020 374.49 374.49

51030 375.11 375.11

51040 231.34 231.34

51045 391.22 391.22

51050 376.31 376.31

51060 461.21 461.21

51065 461.47 461.47

51080 327.53 327.53

51100 49.01 31.06

51101 99.95 41.22

51102 248.27 142.93

51500 508.92 508.92

51520 475.13 475.13

51525 684.59 684.59

51530 637.39 637.39

51535 622.08 622.08

51550 770.26 770.26

51555 1010.49 1010.49

51565 1036.66 1036.66

51570 1177.80 1177.80

51575 1450.11 1450.11

51580 1533.46 1533.46

51585 1684.48 1684.48

51590 1539.62 1539.62

51595 1741.55 1741.55

51596 1873.53 1873.53

CODE NOTE NFAC FAC 26 TC

51597 1825.17 1825.17

51600 161.56

51605 30.68 30.68

51610 90.44 51.39

51700 69.55 33.98

51701 46.89

51702 67.43 23.09

51703 113.63 61.88

51705 91.65 51.41

51710 130.53 72.05

51715 231.31 158.93

51720 77.04 56.72

51725 188.20 188.20 75.49 112.71

51726 265.31 265.31 83.86 181.45

51727 248.97 248.97 83.60 165.37

51728 251.78 251.78 81.50 170.25

51729 271.70 271.70 98.95 172.75

51736 15.26 15.26 8.14 7.12

51741 15.62 15.62 8.14 7.48

51784 68.29 68.29 36.60 31.69

51785 212.97 212.97 70.28 142.69

51792 197.34 197.34 50.14 147.20

51797 111.01 111.01 38.86 72.15

51798 16.24 16.24

51800 833.22 833.22

51820 943.38 943.38

51840 522.84 522.84

51841 623.98 623.98

51845 464.90 464.90

51860 596.98 596.98

51865 714.98 714.98

51880 373.56 373.56

51900 669.33 669.33

51920 625.91 625.91

51925 H 824.28 824.28

51940 1317.69 1317.69

51960 1103.71 1103.71

51980 568.25 568.25

51990 598.59 598.59

51992 668.97 668.97

51999 REPORT REPORT REPORT

52000 143.85 89.45

52001 296.68 229.07

Maryland Medical Assistance FS-60

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

52005 231.95 106.51

52007 485.56 132.32

52010 361.40 132.34

52204 366.93 113.01

52214 617.21 152.39

52224 688.49 162.41

52234 196.37 196.37

52235 230.20 230.20

52240 374.19 374.19

52250 190.84 190.84

52260 167.77 167.77

52265 389.49 129.58

52270 359.10 145.18

52275 495.85 198.24

52276 211.20 211.20

52277 257.59 257.59

52281 259.58 121.61

52282 268.46 268.46

52283 220.49 160.65

52285 222.69 156.28

52287 264.63 139.72

52290 194.41 194.41

52300 223.55 223.55

52301 231.23 231.23

52305 222.44 222.44

52310 204.79 120.97

52315 367.32 218.85

52317 865.30 276.72

52318 377.06 377.06

52320 196.84 196.84

52325 255.94 255.94

52327 285.05 208.63

52330 489.50 210.29

52332 392.57 124.37

52334 203.71 203.71

52341 242.08 242.08

52342 260.38 260.38

52343 286.42 286.42

52344 309.18 309.18

52345 327.79 327.79

52346 366.14 366.14

52351 241.41 241.41

52352 282.06 282.06

CODE NOTE NFAC FAC 26 TC

52353 314.31 314.31

52354 332.36 332.36

52355 372.52 372.52

52356 337.38 337.38

52400 404.68 404.68

52402 212.49 212.49

52441 1089.41 202.74

52442 851.58 59.70

52450 374.89 374.89

52500 400.39 400.39

52601 673.56 673.56

52630 336.54 336.54

52640 294.21 294.21

52647 1773.55 515.93

52648 1823.99 549.57

52649 734.72 734.72

52700 352.49 352.49

53000 117.95 117.95

53010 235.66 235.66

53020 77.47 77.47

53025 57.41 57.41

53040 313.14 313.14

53060 146.30 131.19

53080 346.64 346.64

53085 526.26 526.26

53200 124.20 113.66

53210 620.55 620.55

53215 739.69 739.69

53220 365.45 365.45

53230 482.99 482.99

53235 505.65 505.65

53240 338.87 338.87

53250 326.74 326.74

53260 159.99 143.18

53265 173.45 148.07

53270 164.10 146.71

53275 209.86 209.86

53400 637.60 637.60

53405 700.32 700.32

53410 778.55 778.55

53415 899.73 899.73

53420 669.99 669.99

53425 745.82 745.82

Maryland Medical Assistance FS-61

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

53430 770.02 770.02

53431 918.63 918.63

53440 633.57 633.57

53442 623.74 623.74

53444 631.22 631.22

53445 641.16 641.16

53446 511.72 511.72

53447 643.95 643.95

53448 1020.81 1020.81

53449 487.32 487.32

53450 325.91 325.91

53460 365.21 365.21

53500 596.45 596.45

53502 387.84 387.84

53505 387.27 387.27

53510 502.96 502.96

53515 628.74 628.74

53520 443.29 443.29

53600 66.64 50.63

53601 65.51 42.72

53605 51.38 51.38

53620 98.50 69.70

53621 94.13 57.56

53660 58.17 33.43

53661 57.89

53665 30.81 30.81

53850 2068.19 483.96

53852 1905.41 495.98

53855 627.15 86.55

53860 1263.01 193.24

53899 REPORT REPORT REPORT

54000 125.10 86.57

54001 152.10 110.68

54015 245.46 245.46

54050 106.20 85.11

54055 94.84 74.31

54056 113.65 89.12

54057 108.97 76.20

54060 144.46 104.26

54065 174.66 138.45

54100 158.64 101.05

54105 217.12 170.05

54110 498.87 498.87

CODE NOTE NFAC FAC 26 TC

54111 642.97 642.97

54112 746.81 746.81

54115 362.77 341.11

54120 503.76 503.76

54125 648.84 648.84

54130 950.17 950.17

54135 1203.52 1203.52

54150 144.79 77.90

54160 185.57 114.79

54161 156.99 156.99

54162 216.03 158.37

54163 174.95 174.95

54164 155.19 155.19

54200 85.91 67.03

54205 424.41 424.41

54220 171.44 107.10

54230 76.96 63.56

54231 111.55 93.02

54235 72.04 58.64

54240 83.34 83.34 54.40 28.94

54250 95.67 95.67 86.55 9.12

54300 512.34 512.34

54304 595.98 595.98

54308 569.73 569.73

54312 684.28 684.28

54316 833.81 833.81

54318 566.59 566.59

54322 615.60 615.60

54324 770.00 770.00

54326 753.29 753.29

54328 761.59 761.59

54332 844.70 844.70

54336 947.05 947.05

54340 450.82 450.82

54344 755.25 755.25

54348 807.81 807.81

54352 1127.92 1127.92

54360 574.38 574.38

54380 636.97 636.97

54385 775.38 775.38

54390 987.82 987.82

54400 P 421.83 421.83

54401 P 523.10 523.10

Maryland Medical Assistance FS-62

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

54405 P 643.85 643.85

54406 582.19 582.19

54408 P 630.00 630.00

54410 P 684.79 684.79

54411 P 817.44 817.44

54415 P 421.77 421.77

54416 P 566.54 566.54

54417 P 715.90 715.90

54420 560.65 560.65

54430 509.68 509.68

54435 333.00 333.00

54437 591.34 591.34

54438 1191.32 1191.32

54440 553.07 553.07

54450 56.97 45.95

54500 59.59 59.59

54505 167.51 167.51

54512 431.01 431.01

54520 260.86 260.86

54522 471.80 471.80

54530 403.08 403.08

54535 599.53 599.53

54550 395.79 395.79

54560 574.49 574.49

54600 363.26 363.26

54620 239.07 239.07

54640 382.08 382.08

54650 580.90 580.90

54660 P 290.80 290.80

54670 327.35 327.35

54680 640.31 640.31

54690 526.65 526.65

54692 640.25 640.25

54699 REPORT REPORT REPORT

54700 170.89 170.89

54800 106.49 106.49

54830 297.81 297.81

54840 256.39 256.39

54860 334.23 334.23

54861 450.93 450.93

54865 286.69 286.69

54900 669.33 669.33

54901 840.79 840.79

CODE NOTE NFAC FAC 26 TC

55000 96.98 68.03

55040 270.23 270.23

55041 407.27 407.27

55060 304.22 304.22

55100 172.06 132.73

55110 309.97 309.97

55120 287.85 287.85

55150 392.85 392.85

55175 290.92 290.92

55180 548.73 548.73

55200 423.76 218.36

55250 S 376.71 182.59

55300 149.56 149.56

55400 N.C. N.C.

55500 317.08 317.08

55520 365.69 365.69

55530 280.81 280.81

55535 343.22 343.22

55540 445.87 445.87

55550 341.81 341.81

55559 REPORT REPORT REPORT

55600 336.40 336.40

55605 436.95 436.95

55650 572.99 572.99

55680 292.18 292.18

55700 197.51 104.31

55705 212.34 212.34

55706 297.83 297.83

55720 360.41 360.41

55725 526.85 526.85

55801 874.01 874.01

55810 1043.13 1043.13

55812 1321.98 1321.98

55815 1408.73 1408.73

55821 695.92 695.92

55831 752.48 752.48

55840 979.19 979.19

55842 1048.75 1048.75

55845 1198.70 1198.70

55860 696.86 696.86

55862 894.49 894.49

55865 1062.10 1062.10

55866 1273.47 1273.47

Maryland Medical Assistance FS-63

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

55870 N.C. N.C.

55873 5694.86 756.28

55875 607.50 607.50

55876 112.38 81.99

55899 REPORT REPORT REPORT

55920 355.27 355.27

55970 N.C. N.C.

55980 N.C. N.C.

56405 106.46 103.09

56420 122.92 90.14

56440 176.58 176.58

56441 146.80 135.39

56442 46.97 46.97

56501 127.67 109.43

56515 216.17 188.09

56605 82.22 58.67

56606 38.07 28.93

56620 484.22 484.22

56625 569.41 569.41

56630 822.40 822.40

56631 1051.62 1051.62

56632 1208.56 1208.56

56633 1071.06 1071.06

56634 1137.12 1137.12

56637 1349.38 1349.38

56640 1344.12 1344.12

56700 179.65 179.65

56740 285.11 285.11

56800 233.82 233.82

56805 1101.10 1101.10

56810 251.74 251.74

56820 108.70 81.82

56821 145.99 111.96

57000 183.73 183.73

57010 410.98 410.98

57020 92.82 78.97

57022 161.18 161.18

57023 297.10 297.10

57061 111.32 94.54

57065 188.57 165.70

57100 87.02 63.34

57105 133.15 121.67

57106 449.69 449.69

CODE NOTE NFAC FAC 26 TC

57107 1331.09 1331.09

57109 1520.53 1520.53

57110 862.83 862.83

57111 1550.75 1550.75

57112 1591.46 1591.46

57120 490.90 490.90

57130 177.81 155.09

57135 190.40 167.65

57150 49.21 28.52

57155 348.98 219.37

57156 158.63 115.63

57160 75.85 46.13

57170 66.22 46.87

57180 139.80 105.12

57200 284.64 284.64

57210 351.42 351.42

57220 306.09 306.09

57230 375.31 375.31

57240 600.93 600.93

57250 588.24 588.24

57260 742.31 742.31

57265 840.86 840.86

57267 261.20 261.20

57268 457.46 457.46

57270 761.14 761.14

57280 920.84 920.84

57282 488.41 488.41

57283 657.13 657.13

57284 805.47 805.47

57285 625.16 625.16

57287 665.72 665.72

57288 726.23 726.23

57289 736.44 736.44

57291 525.54 525.54

57292 794.33 794.33

57295 471.32 471.32

57296 894.70 894.70

57300 502.38 502.38

57305 837.46 837.46

57307 938.45 938.45

57308 604.41 604.41

57310 457.46 457.46

57311 519.95 519.95

Maryland Medical Assistance FS-64

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

57320 520.73 520.73

57330 748.59 748.59

57335 1091.61 1091.61

57400 129.84 129.84

57410 102.93 102.93

57415 151.55 151.55

57420 114.18 86.49

57421 154.54 119.37

57423 872.02 872.02

57425 918.04 918.04

57426 879.47 879.47

57452 107.88 88.34

57454 151.67 132.54

57455 141.89 107.62

57456 134.09 100.59

57460 294.64 159.14

57461 330.34 183.47

57500 130.08 71.53

57505 99.67 88.67

57510 130.97 112.71

57511 142.75 127.73

57513 140.76 128.56

57520 302.33 266.35

57522 258.36 234.41

57530 330.37 330.37

57531 1628.89 1628.89

57540 742.97 742.97

57545 786.15 786.15

57550 388.84 388.84

57555 576.42 576.42

57556 542.11 542.11

57558 H 122.53 109.51

57700 289.04 289.04

57720 295.60 295.60

57800 59.46 47.59

58100 108.64 85.42

58110 48.40 40.26

58120 237.05 207.32

58140 873.04 873.04

58145 520.04 520.04

58146 1109.53 1109.53

58150 H 941.31 941.31

58152 H 1197.53 1197.53

CODE NOTE NFAC FAC 26 TC

58180 H 903.66 903.66

58200 H 1247.90 1247.90

58210 H 1661.13 1661.13

58240 H 2544.47 2544.47

58260 H 790.48 790.48

58262 H 883.04 883.04

58263 H 951.08 951.08

58267 H 1010.54 1010.54

58270 H 847.69 847.69

58275 H 940.13 940.13

58280 H 1006.92 1006.92

58285 H 1259.16 1259.16

58290 H 1108.51 1108.51

58291 H 1203.09 1203.09

58292 H 1270.33 1270.33

58293 H 1320.31 1320.31

58294 H 1167.72 1167.72

58300 76.00 51.54

58301 94.93 65.63

58321 N.C. N.C.

58322 N.C. N.C.

58323 N.C. N.C.

58340 126.76 57.98

58345 266.61 266.61

58346 431.49 431.49

58350 94.90 76.33

58353 1110.24 214.17

58356 2069.35 339.99

58400 427.38 427.38

58410 764.50 764.50

58520 745.12 745.12

58540 865.52 865.52

58541 H 776.43 776.43

58542 H 886.97 886.97

58543 H 894.72 894.72

58544 H 977.50 977.50

58545 858.52 858.52

58546 1087.54 1087.54

58548 H 1710.41 1710.41

58550 H 847.76 847.76

58552 H 933.04 933.04

58553 H 1092.19 1092.19

58554 H 1247.30 1247.30

Maryland Medical Assistance FS-65

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

58555 229.29 167.75

58558 1091.60 256.09

58559 315.32 315.32

58560 345.11 345.11

58561 479.15 479.15

58562 295.10 201.29

58563 1399.07 237.42

58565 S 1958.43 433.60

58570 H 846.09 846.09

58571 H 948.49 948.49

58572 H 1075.90 1075.90

58573 H 1210.66 1210.66

58575 H 2065.32 2065.32

58578 REPORT REPORT REPORT

58579 REPORT REPORT REPORT

58600 S 351.71 351.71

58605 S 319.25 319.25

58611 S 75.80 75.80

58615 S 244.99 244.99

58660 644.15 644.15

58661 620.31 620.31

58662 679.69 679.69

58670 S 351.28 351.28

58671 S 351.67 351.67

58672 721.76 721.76

58673 778.44 778.44

58674 703.73 703.73

58679 REPORT REPORT REPORT

58700 S 727.72 727.72

58720 684.66 684.66

58740 836.32 836.32

58750 N.C. N.C.

58752 N.C. N.C.

58760 789.88 789.88

58770 823.42 823.42

58800 310.37 284.73

58805 384.12 384.12

58820 303.09 303.09

58822 653.32 653.32

58825 664.39 664.39

58900 392.35 392.35

58920 673.99 673.99

58925 695.54 695.54

CODE NOTE NFAC FAC 26 TC

58940 476.31 476.31

58943 1066.94 1066.94

58950 1016.27 1016.27

58951 H 1308.99 1308.99

58952 1477.46 1477.46

58953 H 1833.53 1833.53

58954 H 1990.69 1990.69

58956 H 1307.97 1307.97

58957 1387.71 1387.71

58958 1534.71 1534.71

58960 878.40 878.40

58970 N.C. N.C.

58974 N.C. N.C.

58976 N.C. N.C.

58999 REPORT REPORT REPORT

59000 129.36 80.69

59001 179.56 179.56

59012 202.89 202.89

59015 155.04 132.23

59020 69.81 69.81 36.69 33.12

59025 45.87 45.87 28.38 17.49

59030 103.78 103.78

59050 50.76 50.76

59051 41.77 41.77

59070 382.67 271.50

59072 423.80 423.80

59074 354.98 266.63

59076 423.80 423.80

59100 807.96 807.96

59120 768.28 768.28

59121 774.10 774.10

59130 872.46 872.46

59135 H 872.40 872.40

59136 835.97 835.97

59140 360.88 360.88

59150 749.31 749.31

59151 735.50 735.50

59160 213.92 180.38

59200 74.40 44.88

59300 192.40 143.53

59320 152.32 152.32

59325 228.47 228.47

59350 275.38 275.38

Maryland Medical Assistance FS-66

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

59400 N.C. N.C.

59409 860.00 860.00

59410 941.93 941.93

59412 102.16 102.16

59414 89.77 89.77

59425 N.C. N.C.

59426 N.C. N.C.

59430 148.76 125.08

59510 N.C. N.C.

59514 993.44 993.44

59515 1124.12 1124.12

59525 H 477.67 477.67

59610 N.C. N.C.

59612 967.15 967.15

59614 957.87 957.87

59618 N.C. N.C.

59620 934.28 934.28

59622 1154.13 1154.13

59812 300.53 285.47

59820 367.76 338.27

59821 375.03 344.77

59830 427.30 427.30

59840 A 213.33 208.85

59841 A 370.93 348.93

59850 A 364.99 364.99

59851 A 392.96 392.96

59852 A 529.28 529.28

59855 A 407.16 407.16

59856 A 481.97 481.97

59857 A 546.13 546.13

59866 A 225.68 225.68

59870 452.38 452.38

59871 133.23 133.23

59897 REPORT REPORT REPORT

59898 REPORT REPORT REPORT

59899 REPORT REPORT REPORT

60000 126.78 113.95

60100 89.36 62.58

60200 529.45 529.45

60210 567.34 567.34

60212 809.24 809.24

60220 565.48 565.48

60225 746.21 746.21

CODE NOTE NFAC FAC 26 TC

60240 737.02 737.02

60252 1059.32 1059.32

60254 1334.26 1334.26

60260 875.32 875.32

60270 1098.38 1098.38

60271 847.38 847.38

60280 353.50 353.50

60281 472.33 472.33

60300 94.33 39.61

60500 775.43 775.43

60502 1034.75 1034.75

60505 1109.87 1109.87

60512 195.26 195.26

60520 840.90 840.90

60521 904.49 904.49

60522 1099.03 1099.03

60540 855.84 855.84

60545 979.22 979.22

60600 P 1117.45 1117.45

60605 1552.88 1552.88

60650 959.65 959.65

60659 REPORT REPORT REPORT

60699 REPORT REPORT REPORT

61000 102.96 102.96

61001 92.15 92.15

61020 113.78 113.78

61026 115.79 115.79

61050 94.41 94.41

61055 133.63 133.63

61070 63.78 63.78

61105 414.21 414.21

61107 307.59 307.59

61108 807.93 807.93

61120 663.95 663.95

61140 1152.22 1152.22

61150 1233.20 1233.20

61151 902.01 902.01

61154 1149.92 1149.92

61156 1150.64 1150.64

61210 358.44 358.44

61215 436.45 436.45

61250 783.81 783.81

61253 865.83 865.83

Maryland Medical Assistance FS-67

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

61304 1524.56 1524.56

61305 1818.54 1818.54

61312 1881.73 1881.73

61313 1810.69 1810.69

61314 1669.87 1669.87

61315 1919.65 1919.65

61316 83.29 83.29

61320 1772.39 1772.39

61321 1962.00 1962.00

61322 2125.27 2125.27

61323 2174.45 2174.45

61330 1457.61 1457.61

61332 1734.67 1734.67

61333 1720.77 1720.77

61340 1329.48 1329.48

61343 2037.32 2037.32

61345 1874.72 1874.72

61450 1736.69 1736.69

61458 1863.69 1863.69

61460 1885.23 1885.23

61480 1620.65 1620.65

61500 1242.56 1242.56

61501 1054.15 1054.15

61510 2007.51 2007.51

61512 2381.51 2381.51

61514 1758.76 1758.76

61516 1718.49 1718.49

61517 84.10 84.10

61518 2561.54 2561.54

61519 2759.71 2759.71

61520 3508.41 3508.41

61521 2972.27 2972.27

61522 2014.76 2014.76

61524 1924.49 1924.49

61526 3160.67 3160.67

61530 2685.85 2685.85

61531 1097.52 1097.52

61533 1396.71 1396.71

61534 1499.34 1499.34

61535 890.06 890.06

61536 2410.60 2410.60

61537 2147.72 2147.72

61538 2288.16 2288.16

CODE NOTE NFAC FAC 26 TC

61539 2183.44 2183.44

61540 2065.52 2065.52

61541 1957.14 1957.14

61543 1965.25 1965.25

61544 1678.27 1678.27

61545 2936.07 2936.07

61546 2122.59 2122.59

61548 1418.44 1418.44

61550 987.17 987.17

61552 1161.99 1161.99

61556 1495.33 1495.33

61557 1563.97 1563.97

61558 1567.08 1567.08

61559 2167.47 2167.47

61563 1738.26 1738.26

61564 2248.74 2248.74

61566 2064.64 2064.64

61567 2311.36 2311.36

61570 1690.36 1690.36

61571 1827.58 1827.58

61575 2169.49 2169.49

61576 3364.46 3364.46

61580 2281.33 2281.33

61581 2514.88 2514.88

61582 2639.63 2639.63

61583 2696.49 2696.49

61584 2620.93 2620.93

61585 2762.85 2762.85

61586 2014.33 2014.33

61590 2883.29 2883.29

61591 2910.60 2910.60

61592 2931.73 2931.73

61595 2178.02 2178.02

61596 2389.42 2389.42

61597 2664.78 2664.78

61598 2379.22 2379.22

61600 1963.67 1963.67

61601 2181.38 2181.38

61605 2053.29 2053.29

61606 2764.78 2764.78

61607 2563.10 2563.10

61608 3033.38 3033.38

61610 1794.11 1794.11

Maryland Medical Assistance FS-68

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

61611 407.56 407.56

61612 1301.39 1301.39

61613 2942.22 2942.22

61615 2288.01 2288.01

61616 3037.98 3037.98

61618 1198.75 1198.75

61619 1385.88 1385.88

61623 536.83 536.83

61624 1047.07 1047.07

61626 845.33 845.33

61630 1212.19 1212.19

61635 1326.41 1326.41

61640 527.40 527.40

61641 185.19 185.19

61642 370.37 370.37

61645 857.36 857.36

61650 588.22 588.22

61651 250.63 250.63

61680 2101.30 2101.30

61682 3977.44 3977.44

61684 2667.75 2667.75

61686 4255.41 4255.41

61690 2002.48 2002.48

61692 3419.37 3419.37

61697 3793.52 3793.52

61698 4006.23 4006.23

61700 3268.31 3268.31

61702 3537.07 3537.07

61703 1209.14 1209.14

61705 2395.16 2395.16

61708 1966.17 1966.17

61710 1791.29 1791.29

61711 2437.66 2437.66

61720 1065.64 1065.64

61735 1326.66 1326.66

61750 1290.39 1290.39

61751 1259.86 1259.86

61760 1386.22 1386.22

61770 1371.28 1371.28

61781 256.99 256.99

61782 193.59 193.59

61783 256.99 256.99

61790 776.20 776.20

CODE NOTE NFAC FAC 26 TC

61791 999.29 999.29

61796 844.69 844.69

61797 206.30 206.30

61798 1148.93 1148.93

61799 285.26 285.26

61800 146.77 146.77

61850 890.82 890.82

61860 1424.07 1424.07

61863 1399.56 1399.56

61864 306.96 306.96

61867 2025.03 2025.03

61868 540.70 540.70

61870 1094.99 1094.99

61880 495.33 495.33

61885 563.34 563.34

61886 709.02 709.02

61888 373.05 373.05

62000 789.41 789.41

62005 1118.57 1118.57

62010 1399.62 1399.62

62100 1487.07 1487.07

62115 1282.45 1282.45

62117 1706.07 1706.07

62120 1672.54 1672.54

62121 1543.23 1543.23

62140 969.03 969.03

62141 1060.74 1060.74

62142 804.06 804.06

62143 948.03 948.03

62145 1282.25 1282.25

62146 1112.47 1112.47

62147 1318.19 1318.19

62148 118.87 118.87

62160 185.12 185.12

62161 1409.67 1409.67

62162 1733.29 1733.29

62163 1101.29 1101.29

62164 1829.26 1829.26

62165 1411.97 1411.97

62180 1455.60 1455.60

62190 801.84 801.84

62192 884.37 884.37

62194 364.29 364.29

Maryland Medical Assistance FS-69

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

62200 1268.77 1268.77

62201 1083.87 1083.87

62220 942.05 942.05

62223 950.86 950.86

62225 455.86 455.86

62230 768.20 768.20

62252 96.30 96.30 53.47 42.83

62256 529.79 529.79

62258 1037.99 1037.99

62263 528.44 282.03

62264 379.67 214.48

62267 247.36 162.34

62268 283.98 257.88

62269 293.44 254.62

62270 149.59 72.93

62272 177.93 79.68

62273 158.29 103.92

62280 296.07 144.96

62281 264.94 136.60

62282 283.08 127.07

62284 206.19 85.94

62287 524.45 524.45

62290 314.84 161.89

62291 295.19 155.48

62292 475.13 475.13

62294 788.94 788.94

62302 264.29 132.73

62303 274.74 134.68

62304 260.47 130.47

62305 284.55 136.10

62320 164.92 100.85

62321 246.43 108.72

62322 154.00 86.73

62323 242.00 98.98

62324 143.56 91.52

62325 217.70 105.13

62326 151.11 89.87

62327 222.44 95.69

62350 376.75 376.75

62351 779.04 779.04

62355 282.35 282.35

62360 257.26 257.26

62361 372.97 372.97

CODE NOTE NFAC FAC 26 TC

62362 397.80 397.80

62365 313.66 313.66

62367 36.99 21.82

62368 52.98 34.67

62369 130.76 37.01

62370 137.69 49.61

62380 904.37 904.37

63001 1131.87 1131.87

63003 1141.08 1141.08

63005 1083.04 1083.04

63011 1017.56 1017.56

63012 1106.74 1106.74

63015 1368.64 1368.64

63016 1397.26 1397.26

63017 1145.41 1145.41

63020 1085.92 1085.92

63030 904.37 904.37

63035 193.75 193.75

63040 1323.82 1323.82

63042 1242.25 1242.25

63043 475.05 475.05

63044 393.94 393.94

63045 1179.64 1179.64

63046 1124.93 1124.93

63047 1032.80 1032.80

63048 206.31 206.31

63050 1404.05 1404.05

63051 1581.80 1581.80

63055 1519.43 1519.43

63056 1408.61 1408.61

63057 319.06 319.06

63064 1667.69 1667.69

63066 195.39 195.39

63075 1309.39 1309.39

63076 247.03 247.03

63077 1411.66 1411.66

63078 195.00 195.00

63081 1661.73 1661.73

63082 266.23 266.23

63085 1759.47 1759.47

63086 187.19 187.19

63087 2243.45 2243.45

63088 254.56 254.56

Maryland Medical Assistance FS-70

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

63090 1826.56 1826.56

63091 174.31 174.31

63101 2110.35 2110.35

63102 2106.28 2106.28

63103 276.29 276.29

63170 1390.61 1390.61

63172 1282.08 1282.08

63173 1576.90 1576.90

63180 1291.23 1291.23

63182 1361.24 1361.24

63185 1027.53 1027.53

63190 1163.63 1163.63

63191 1179.37 1179.37

63194 1338.21 1338.21

63195 1389.98 1389.98

63196 1505.97 1505.97

63197 1420.49 1420.49

63198 1611.38 1611.38

63199 1611.99 1611.99

63200 1391.02 1391.02

63250 2663.48 2663.48

63251 2810.34 2810.34

63252 2798.04 2798.04

63265 1538.09 1538.09

63266 1583.83 1583.83

63267 1276.06 1276.06

63268 1257.75 1257.75

63270 1897.69 1897.69

63271 1906.25 1906.25

63272 1757.37 1757.37

63273 1694.36 1694.36

63275 1657.53 1657.53

63276 1646.39 1646.39

63277 1450.57 1450.57

63278 1416.72 1416.72

63280 1958.90 1958.90

63281 1941.78 1941.78

63282 1828.95 1828.95

63283 1741.95 1741.95

63285 2414.90 2414.90

63286 2413.60 2413.60

63287 2532.69 2532.69

63290 2540.25 2540.25

CODE NOTE NFAC FAC 26 TC

63295 301.16 301.16

63300 1707.87 1707.87

63301 1880.46 1880.46

63302 1869.15 1869.15

63303 1964.58 1964.58

63304 2101.00 2101.00

63305 2158.68 2158.68

63306 2223.74 2223.74

63307 1997.44 1997.44

63308 320.14 320.14

63600 760.58 760.58

63610 491.57 405.15

63615 1056.32 1056.32

63620 930.71 930.71

63621 237.22 237.22

63650 1050.33 389.67

63655 777.59 777.59

63661 557.02 307.59

63662 709.11 709.11

63663 825.43 476.03

63664 738.46 738.46

63685 382.88 382.88

63688 342.75 342.75

63700 1136.03 1136.03

63702 1240.49 1240.49

63704 1431.26 1431.26

63706 1661.74 1661.74

63707 838.44 838.44

63709 1020.32 1020.32

63710 1020.91 1020.91

63740 855.45 855.45

63741 566.96 566.96

63744 598.07 598.07

63746 498.90 498.90

64400 102.20 58.38

64402 107.29 68.25

64405 98.20 67.33

64408 113.12 83.40

64410 132.35 72.79

64413 109.13 70.44

64415 124.26 69.04

64416 84.33 84.33

64417 125.87 69.47

Maryland Medical Assistance FS-71

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

64418 127.93 66.95

64420 121.37 60.69

64421 163.48 82.46

64425 122.34 85.94

64430 149.84 80.45

64435 139.63 80.73

64445 129.22 74.31

64446 84.87 84.87

64447 93.93 66.55

64448 76.21 76.21

64449 87.27 87.27

64450 87.68 49.53

64455 50.72 37.67

64461 161.88 94.10

64462 91.69 59.09

64463 179.95 91.92

64479 256.59 114.00

64480 122.94 69.06

64483 238.48 100.76

64484 95.34 55.42

64486 133.09 67.80

64487 146.99 73.04

64488 152.34 79.96

64489 195.03 84.90

64490 189.42 110.85

64491 95.09 63.43

64492 96.23 64.58

64493 169.63 94.14

64494 86.56 54.14

64495 87.70 55.28

64505 97.02 78.60

64508 65.09 66.88

64510 134.95 63.08

64517 161.23 110.77

64520 177.07 70.53

64530 182.82 83.90

64550 14.97 8.59

64553 193.50 151.57

64555 204.87 139.72

64561 910.11 332.65

64566 138.74 31.19

64568 678.53 678.53

64569 669.36 669.36

CODE NOTE NFAC FAC 26 TC

64570 591.66 591.66

64575 268.35 268.35

64580 280.72 280.72

64581 728.18 728.18

64585 270.35 155.42

64590 292.53 173.15

64595 271.85 137.64

64600 385.11 197.41

64605 544.86 311.99

64610 670.50 449.30

64611 107.00 96.69

64612 144.50 125.45

64615 127.80 114.93

64616 127.56 112.25

64617 197.65 118.59

64620 221.79 154.50

64630 222.92 176.93

64632 81.97 69.77

64633 458.41 246.03

64634 206.36 74.21

64635 453.41 242.57

64636 187.80 64.68

64640 144.79 101.92

64642 144.41 111.20

64643 94.77 73.92

64644 164.96 122.07

64645 116.14 84.78

64646 155.30 119.58

64647 179.72 138.38

64650 62.14 35.57

64653 75.85 44.56

64680 292.50 149.67

64681 422.20 220.14

64702 414.89 414.89

64704 314.31 314.31

64708 432.59 432.59

64712 497.65 497.65

64713 696.19 696.19

64714 574.66 574.66

64716 489.93 489.93

64718 528.50 528.50

64719 372.04 372.04

64721 392.81 391.28

Maryland Medical Assistance FS-72

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

64722 302.15 302.15

64726 277.77 277.77

64727 178.25 178.25

64732 346.88 346.88

64734 412.90 412.90

64736 351.79 351.79

64738 440.81 440.81

64740 434.91 434.91

64742 439.84 439.84

64744 401.78 401.78

64746 421.05 421.05

64755 805.57 805.57

64760 432.94 432.94

64763 474.65 474.65

64766 560.78 560.78

64771 547.44 547.44

64772 521.11 521.11

64774 381.97 381.97

64776 367.21 367.21

64778 153.80 153.80

64782 425.28 425.28

64783 210.80 210.80

64784 673.88 673.88

64786 1019.86 1019.86

64787 244.55 244.55

64788 355.77 355.77

64790 776.09 776.09

64792 977.78 977.78

64795 182.81 182.81

64802 573.18 573.18

64804 850.78 850.78

64809 814.34 814.34

64818 622.04 622.04

64820 704.70 704.70

64821 642.08 642.08

64822 639.91 639.91

64823 724.17 724.17

64831 645.24 645.24

64832 331.32 331.32

64834 698.35 698.35

64835 757.69 757.69

64836 758.23 758.23

64837 367.38 367.38

CODE NOTE NFAC FAC 26 TC

64840 844.57 844.57

64856 949.10 949.10

64857 992.66 992.66

64858 1143.07 1143.07

64859 250.14 250.14

64861 1304.53 1304.53

64862 1309.77 1309.77

64864 830.81 830.81

64865 1101.80 1101.80

64866 1140.12 1140.12

64868 989.22 989.22

64872 116.47 116.47

64874 173.74 173.74

64876 190.59 190.59

64885 1075.22 1075.22

64886 1270.78 1270.78

64890 1021.80 1021.80

64891 997.99 997.99

64892 991.82 991.82

64893 1065.90 1065.90

64895 1208.27 1208.27

64896 1323.68 1323.68

64897 1182.99 1182.99

64898 1286.97 1286.97

64901 580.01 580.01

64902 676.68 676.68

64905 901.26 901.26

64907 1181.58 1181.58

64910 659.82 659.82

64911 815.99 815.99

64912 687.02 687.02

64913 138.73 138.73

64999 REPORT REPORT REPORT

65091 501.27 501.27

65093 495.35 495.35

65101 582.25 582.25

65103 606.95 606.95

65105 668.41 668.41

65110 963.57 963.57

65112 1118.62 1118.62

65114 1163.98 1163.98

65125 358.87 228.31

65130 575.96 575.96

Maryland Medical Assistance FS-73

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

65135 584.82 584.82

65140 635.24 635.24

65150 456.17 456.17

65155 665.07 665.07

65175 518.39 518.39

65205 44.11 34.43

65210 53.88 41.63

65220 45.98 33.43

65222 52.46 40.77

65235 558.54 558.54

65260 755.33 755.33

65265 849.86 849.86

65270 210.58 110.26

65272 397.20 276.05

65273 299.82 299.82

65275 455.43 362.80

65280 527.83 527.83

65285 870.74 870.74

65286 556.36 389.62

65290 387.12 387.12

65400 535.88 475.16

65410 112.76 82.26

65420 408.74 297.89

65426 515.42 376.88

65430 89.64 81.37

65435 62.89 54.91

65436 304.80 292.55

65450 256.55 253.98

65600 311.21 271.31

65710 869.36 869.36

65730 964.60 964.60

65750 969.12 969.12

65755 964.16 964.16

65756 929.90 929.90

65757 229.26 229.26

65760 603.00 603.00

65765 603.00 603.00

65767 625.00 625.00

65770 1100.38 1100.38

65771 N.C. N.C.

65772 355.67 320.03

65775 433.92 433.92

65778 1142.09 55.62

CODE NOTE NFAC FAC 26 TC

65779 964.11 147.89

65780 557.32 557.32

65781 1047.76 1047.76

65782 904.53 904.53

65785 1863.32 335.77

65800 97.54 82.64

65810 366.44 366.44

65815 503.83 376.16

65820 589.43 589.43

65850 659.45 659.45

65855 227.20 194.96

65860 242.97 199.07

65865 372.52 372.52

65870 465.37 465.37

65875 496.31 496.31

65880 522.21 522.21

65900 757.66 757.66

65920 620.13 620.13

65930 501.06 501.06

66020 147.54 103.37

66030 131.54 87.36

66130 548.72 447.54

66150 690.51 690.51

66155 689.96 689.96

66160 777.23 777.23

66170 861.09 861.09

66172 937.42 937.42

66174 817.71 817.71

66175 932.72 932.72

66179 847.59 927.52

66180 894.11 894.11

66183 882.71 882.71

66184 618.24 677.53

66185 664.47 664.47

66220 558.99 558.99

66225 732.39 732.39

66250 591.82 438.78

66500 279.63 279.63

66505 308.54 308.54

66600 655.55 655.55

66605 830.14 830.14

66625 337.95 337.95

66630 448.15 448.15

Maryland Medical Assistance FS-74

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

66635 452.01 452.01

66680 408.01 408.01

66682 502.78 502.78

66700 354.71 309.41

66710 346.16 309.12

66711 506.34 506.34

66720 363.37 322.89

66740 343.89 309.12

66761 284.67 253.13

66762 374.28 335.80

66770 415.83 381.07

66820 311.53 311.53

66821 260.35 245.54

66825 598.69 598.69

66830 560.83 560.83

66840 547.67 547.67

66850 623.21 623.21

66852 663.41 663.41

66920 592.82 592.82

66930 671.90 671.90

66940 614.92 614.92

66982 677.60 677.60

66983 581.59 581.59

66984 503.10 503.10

66985 605.58 605.58

66986 714.17 714.17

66990 70.79 70.79

66999 REPORT REPORT REPORT

67005 372.04 372.04

67010 426.83 426.83

67015 456.93 456.93

67025 572.20 497.81

67027 669.64 669.64

67028 99.41 98.00

67030 419.86 419.86

67031 306.25 280.89

67036 708.12 708.12

67039 767.42 767.42

67040 883.52 883.52

67041 904.21 904.21

67042 919.72 919.72

67043 966.45 966.45

67101 321.41 278.57

CODE NOTE NFAC FAC 26 TC

67105 290.52 269.28

67107 889.37 889.37

67108 994.22 994.22

67110 690.68 639.92

67113 1061.99 1061.99

67115 393.97 393.97

67120 518.57 439.33

67121 713.90 713.90

67141 412.38 384.17

67145 414.66 392.14

67208 471.50 454.95

67210 430.19 412.94

67218 1085.46 1085.46

67220 522.37 489.46

67221 225.81 167.37

67225 23.16 22.02

67227 283.54 250.96

67228 332.73 299.82

67229 915.67 915.67

67250 614.47 614.47

67255 538.41 538.41

67299 REPORT REPORT REPORT

67311 470.17 470.17

67312 559.09 559.09

67314 528.91 528.91

67316 629.72 629.72

67318 555.15 555.15

67320 252.58 252.58

67331 239.92 239.92

67332 260.30 260.30

67334 236.32 236.32

67335 116.50 116.50

67340 280.95 280.95

67343 514.70 514.70

67345 191.53 172.43

67346 152.37 152.37

67399 REPORT REPORT REPORT

67400 732.28 732.28

67405 624.74 624.74

67412 669.93 669.93

67413 672.89 672.89

67414 1042.76 1042.76

67415 82.36 82.36

Maryland Medical Assistance FS-75

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

67420 1273.04 1273.04

67430 973.64 973.64

67440 948.82 948.82

67445 1101.93 1101.93

67450 984.27 984.27

67500 60.95 55.82

67505 69.46 63.47

67515 76.09 70.11

67550 759.39 759.39

67560 777.79 777.79

67570 921.90 921.90

67599 REPORT REPORT REPORT

67700 213.22 91.81

67710 177.54 76.64

67715 190.45 85.57

67800 99.73 81.49

67801 127.43 104.62

67805 158.49 129.42

67808 290.19 290.19

67810 146.72 61.01

67820 39.27 41.84

67825 101.12 95.70

67830 210.63 108.60

67835 345.58 345.58

67840 217.79 124.60

67850 170.69 107.71

67875 135.79 76.79

67880 361.66 290.41

67882 444.55 371.87

67900 505.43 401.67

67901 597.49 454.39

67902 568.91 568.91

67903 467.78 380.87

67904 577.46 470.57

67906 399.68 399.68

67908 388.69 334.23

67909 423.21 345.97

67911 442.79 442.79

67912 698.55 386.72

67914 371.92 258.78

67915 237.63 162.30

67916 468.05 340.09

67917 475.82 360.96

CODE NOTE NFAC FAC 26 TC

67921 364.32 245.19

67922 230.97 157.80

67923 467.08 339.38

67924 497.73 360.90

67930 287.71 188.82

67935 469.14 348.29

67938 193.52 91.77

67950 451.91 365.55

67961 453.40 358.50

67966 604.90 517.37

67971 568.94 568.94

67973 731.77 731.77

67974 729.77 729.77

67975 538.41 538.41

67999 REPORT REPORT REPORT

68020 94.01 86.88

68040 48.45 39.33

68100 134.33 76.76

68110 178.30 117.02

68115 246.34 144.87

68130 425.19 324.59

68135 123.19 118.92

68200 32.56

68320 572.38 425.05

68325 518.46 518.46

68326 508.49 508.49

68328 557.96 557.96

68330 477.13 363.43

68335 510.41 510.41

68340 430.25 314.51

68360 420.04 324.86

68362 516.68 516.68

68371 325.45 325.45

68399 REPORT REPORT REPORT

68400 225.19 103.77

68420 254.18 132.48

68440 80.47 78.18

68500 770.12 770.12

68505 762.71 762.71

68510 350.54 228.83

68520 540.77 540.77

68525 207.19 207.19

68530 337.74 202.64

Maryland Medical Assistance FS-76

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

68540 730.85 730.85

68550 876.11 876.11

68700 475.47 475.47

68705 186.98 131.11

68720 595.54 595.54

68745 597.75 597.75

68750 619.25 619.25

68760 158.99 115.09

68761 116.51 93.71

68770 495.63 495.63

68801 80.76 68.54

68810 154.40 125.03

68811 130.45 130.45

68815 315.15 174.94

68816 515.33 153.67

68840 100.76 91.92

68850 48.62 44.63

68899 REPORT REPORT REPORT

69000 159.72 101.73

69005 185.71 139.10

69020 204.75 126.68

69090 N.C. N.C.

69100 94.00 41.32

69105 123.77 57.45

69110 395.64 289.53

69120 361.06 361.06

69140 779.42 779.42

69145 326.36 217.68

69150 941.32 941.32

69155 1490.49 1490.49

69200 81.84 48.52

69205 90.87 90.87

69209 11.27 11.27

69210 43.91 28.75

69220 89.22 55.22

69222 197.32 124.17

69300 P 472.35 415.20

69310 975.60 975.60

69320 1381.50 1381.50

69399 REPORT REPORT REPORT

69420 169.42 106.12

69421 136.79 136.79

69424 115.06 55.18

CODE NOTE NFAC FAC 26 TC

69433 175.09 114.84

69436 148.82 148.82

69440 601.75 601.75

69450 471.12 471.12

69501 649.22 649.22

69502 857.63 857.63

69505 1081.92 1081.92

69511 1108.93 1108.93

69530 1477.39 1477.39

69535 2395.74 2395.74

69540 186.73 114.73

69550 933.10 933.10

69552 1415.73 1415.73

69554 2262.86 2262.86

69601 925.28 925.28

69602 964.04 964.04

69603 1145.46 1145.46

69604 987.42 987.42

69605 1402.77 1402.77

69610 351.74 264.19

69620 622.43 434.83

69631 773.08 773.08

69632 949.73 949.73

69633 915.36 915.36

69635 1088.07 1088.07

69636 1237.86 1237.86

69637 1231.24 1231.24

69641 919.49 919.49

69642 1186.19 1186.19

69643 1082.16 1082.16

69644 1330.99 1330.99

69645 1303.20 1303.20

69646 1384.12 1384.12

69650 703.39 703.39

69660 822.59 822.59

69661 1078.46 1078.46

69662 1031.68 1031.68

69666 712.69 712.69

69667 714.18 714.18

69670 835.36 835.36

69676 736.90 736.90

69700 625.45 625.45

69710 P 814.54 814.54

Maryland Medical Assistance FS-77

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

69711 P 763.65 763.65

69714 955.97 955.97

69715 1184.84 1184.84

69717 1016.10 1016.10

69718 1261.48 1261.48

69720 1042.98 1042.98

69725 1677.92 1677.92

69740 1030.78 1030.78

69745 1047.19 1047.19

69799 REPORT REPORT REPORT

69801 214.80 124.67

69805 931.32 931.32

69806 837.76 837.76

69905 808.96 808.96

69910 906.60 906.60

69915 1369.66 1369.66

69930 1133.05 1133.05

69949 REPORT REPORT REPORT

69950 1626.72 1626.72

69955 1785.32 1785.32

69960 1720.79 1720.79

69970 1915.44 1915.44

69979 REPORT REPORT REPORT

69990 199.26 199.26

70010 65.23 65.23 18.73 46.50

70015 123.70 123.70 50.21 73.48

70030 21.98 21.98 6.48 15.50

70100 26.24 26.24 7.11 19.12

70110 30.09 30.09 9.84 20.26

70120 26.81 26.81 7.19 19.62

70130 43.36 43.36 13.51 29.85

70134 41.04 41.04 13.85 27.20

70140 24.67 24.67 8.59 16.08

70150 33.48 33.48 10.56 22.92

70160 25.97 25.97 6.78 19.20

70170 44.76 44.76 11.76 33.00

70190 28.18 28.18 8.68 19.50

70200 34.64 34.64 11.50 23.14

70210 24.09 24.09 6.97 17.12

70220 31.71 31.71 10.46 21.26

70240 23.94 23.94 7.49 16.45

70250 28.69 28.69 9.75 18.94

70260 38.70 38.70 14.63 24.06

CODE NOTE NFAC FAC 26 TC

70300 11.85 11.85 4.69 7.16

70310 28.84 28.84 6.12 22.72

70320 42.45 42.45 9.72 32.73

70328 24.25 24.25 7.11 17.13

70330 38.38 38.38 9.79 28.59

70332 73.45 73.45 27.57 45.88

70336 296.13 296.13 67.40 228.73

70350 16.67 16.67 8.34 8.33

70355 20.48 20.48 10.92 9.56

70360 22.27 22.27 6.48 15.79

70370 61.35 61.35 13.13 48.21

70371 82.84 82.84 38.27 44.57

70380 28.86 28.86 7.37 21.48

70390 76.39 76.39 15.01 61.38

70450 114.38 114.38 41.13 73.25

70460 159.80 159.80 54.60 105.18

70470 189.24 189.24 61.50 127.74

70480 173.29 173.29 59.99 113.30

70481 266.69 266.69 65.39 201.32

70482 306.40 306.40 72.00 234.40

70486 137.39 137.39 41.38 96.01

70487 165.11 165.11 54.22 110.89

70488 201.64 201.64 61.40 140.24

70490 173.29 173.29 64.97 108.31

70491 255.34 255.34 85.21 170.13

70492 274.54 274.54 89.09 185.45

70496 319.95 319.95 93.43 226.52

70498 320.24 320.24 93.73 226.51

70540 316.79 316.79 76.85 239.94

70542 368.69 368.69 90.70 277.99

70543 411.89 411.89 106.23 305.66

70544 311.47 311.47 60.55 250.92

70545 353.06 353.06 66.98 286.08

70546 475.29 475.29 70.39 404.90

70547 311.17 311.17 60.77 250.40

70548 353.37 353.37 80.07 273.30

70549 475.29 475.29 82.65 392.64

70551 227.74 227.74 71.76 155.98

70552 316.38 316.38 85.96 230.42

70553 372.66 372.66 109.93 262.73

70554 444.90 444.90 101.93 342.97

70555 13.34 13.34 13.34

70557 205.36 205.36 205.36

Maryland Medical Assistance FS-78

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

70558 227.07 227.07 227.07

70559 228.04 228.04 228.04

71045 17.29 17.29 7.83 9.46

71046 26.61 26.61 9.32 17.29

71047 34.03 34.03 12.04 21.99

71048 36.46 36.46 13.83 22.62

71100 26.17 26.17 8.66 17.51

71101 30.81 30.81 10.85 19.96

71110 32.87 32.87 11.88 20.99

71111 40.53 40.53 13.95 26.58

71120 26.73 26.73 8.97 17.76

71130 29.40 29.40 8.96 20.45

71250 160.76 160.76 56.43 104.33

71260 226.84 226.84 70.25 156.59

71270 271.87 271.87 78.19 193.68

71275 326.65 326.65 96.85 229.80

71550 320.76 320.76 72.75 248.01

71551 372.39 372.39 68.48 303.91

71552 511.92 511.92 100.13 411.79

71555 375.66 375.66 81.93 293.73

72020 18.61 18.61 6.33 12.28

72040 28.20 28.20 9.33 18.87

72050 40.25 40.25 13.79 26.46

72052 50.58 50.58 16.19 34.39

72070 27.02 27.02 8.75 18.27

72072 30.27 30.27 9.29 20.98

72074 35.91 35.91 9.80 26.10

72080 27.91 27.91 9.14 18.78

72081 33.58 33.58 11.41 22.17

72082 54.10 54.10 13.74 40.36

72083 58.70 58.70 13.98 44.72

72084 69.82 69.82 16.77 53.05

72100 29.69 29.69 9.32 20.37

72110 41.44 41.44 13.15 28.29

72114 53.86 53.86 14.13 39.72

72120 37.40 37.40 10.09 27.31

72125 163.12 163.12 50.03 113.09

72126 225.83 225.83 59.17 166.66

72127 267.13 267.13 61.01 206.12

72128 159.74 159.74 46.96 112.78

72129 226.89 226.89 59.15 167.74

72130 268.19 268.19 61.20 206.99

72131 159.74 159.74 46.96 112.78

CODE NOTE NFAC FAC 26 TC

72132 225.47 225.47 59.07 166.40

72133 266.77 266.77 61.49 205.28

72141 221.41 221.41 71.76 149.65

72142 321.33 321.33 86.05 235.31

72146 221.76 221.76 71.76 150.00

72147 319.20 319.20 85.77 233.43

72148 220.70 220.70 71.53 149.17

72149 317.84 317.84 86.29 231.55

72156 375.14 375.14 110.03 265.11

72157 375.85 375.85 110.05 265.80

72158 373.73 373.73 110.18 263.55

72159 412.26 412.26 106.61 305.65

72170 25.40 25.40 6.85 18.55

72190 30.17 30.17 8.48 21.69

72191 322.64 322.64 92.82 229.82

72192 143.96 143.96 52.66 91.30

72193 223.49 223.49 56.39 167.10

72194 257.33 257.33 59.01 198.32

72195 320.73 320.73 72.74 247.99

72196 372.64 372.64 90.66 281.98

72197 511.60 511.60 128.82 382.78

72198 375.06 375.06 80.98 294.08

72200 22.64 22.64 6.88 15.76

72202 27.33 27.33 7.69 19.64

72220 23.80 23.80 7.23 16.57

72240 96.54 96.54 43.96 52.57

72255 96.94 96.94 45.09 51.85

72265 90.71 90.71 39.90 50.81

72270 124.72 124.72 64.90 59.82

72275 91.65 91.65 30.29 61.36

72285 110.56 110.56 58.21 52.35

72295 96.07 96.07 42.09 53.98

73000 22.00 22.00 6.50 15.50

73010 23.98 23.98 7.05 16.93

73020 18.80 18.80 6.48 12.32

73030 23.78 23.78 7.52 16.26

73040 85.06 85.06 22.52 62.53

73050 28.22 28.22 8.14 20.08

73060 23.50 23.50 6.69 16.82

73070 21.74 21.74 6.32 15.42

73080 26.19 26.19 7.14 19.05

73085 79.12 79.12 23.34 55.77

73090 21.47 21.47 6.87 14.60

Maryland Medical Assistance FS-79

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

73092 22.00 22.00 6.38 15.62

73100 23.14 23.14 6.32 16.82

73110 28.25 28.25 6.92 21.33

73115 84.66 84.66 22.11 62.55

73120 21.17 21.17 6.18 15.00

73130 24.55 24.55 6.62 17.93

73140 25.19 25.19 5.38 19.81

73200 159.74 159.74 46.96 112.78

73201 219.95 219.95 56.29 163.66

73202 297.79 297.79 63.91 233.88

73206 322.61 322.61 86.04 236.57

73218 316.79 316.79 67.73 249.06

73219 368.69 368.69 72.23 296.46

73220 487.61 487.61 102.11 385.50

73221 234.46 234.46 65.70 168.76

73222 368.66 368.66 77.09 291.57

73223 507.48 507.48 112.91 394.57

73225 404.99 404.99 101.37 303.62

73501 25.92 25.92 8.01 17.92

73502 35.83 35.83 9.51 26.34

73503 44.81 44.81 12.26 32.55

73521 34.58 34.58 10.13 24.45

73522 42.27 42.27 12.82 29.45

73523 49.10 49.10 13.73 35.37

73525 80.96 80.96 22.47 58.49

73551 24.08 24.08 7.11 16.97

73552 28.10 28.10 7.93 20.17

73560 24.56 24.56 6.51 18.05

73562 28.52 28.52 7.40 21.12

73564 31.58 31.58 8.75 22.83

73565 28.56 28.56 6.87 21.69

73580 98.12 98.12 23.70 74.42

73590 22.85 22.85 6.58 16.27

73592 22.00 22.00 6.38 15.62

73600 23.71 23.71 6.58 17.13

73610 25.11 25.11 6.85 18.26

73615 83.77 83.77 22.16 61.61

73620 20.87 20.87 6.01 14.86

73630 23.84 23.84 6.68 17.16

73650 21.43 21.43 6.21 15.22

73660 22.35 22.35 5.15 17.20

73700 159.74 159.74 46.96 112.78

73701 223.49 223.49 56.39 167.10

CODE NOTE NFAC FAC 26 TC

73702 298.09 298.09 64.42 233.67

73706 326.08 326.08 87.72 238.36

73718 316.79 316.79 68.14 248.65

73719 368.69 368.69 88.56 280.13

73720 487.32 487.32 119.69 367.63

73721 234.11 234.11 65.60 168.51

73722 368.66 368.66 76.57 292.09

73723 507.79 507.79 112.78 395.01

73725 375.65 375.65 82.00 293.65

74018 23.87 23.87 7.83 16.04

74019 29.10 29.10 9.92 19.18

74021 34.09 34.09 11.78 22.31

74022 36.68 36.68 13.05 23.63

74150 147.30 147.30 57.65 89.65

74160 228.19 228.19 61.43 166.76

74170 259.43 259.43 67.82 191.61

74174 367.56 367.56 109.46 258.10

74175 325.51 325.51 93.52 231.99

74176 181.41 181.41 77.43 103.98

74177 286.56 286.56 82.10 204.46

74178 363.20 363.20 101.88 261.32

74181 320.98 320.98 80.98 240.00

74182 372.68 372.68 82.25 290.43

74183 511.60 511.60 128.46 383.14

74185 375.06 375.06 80.83 294.23

74190 65.00 65.00 20.13 44.87

74210 61.84 61.84 13.88 47.95

74220 70.24 70.24 18.02 52.22

74230 102.03 102.03 20.58 81.44

74235 51.00 51.00 51.00

74240 89.51 89.51 27.01 62.50

74241 93.50 93.50 26.90 66.60

74245 136.15 136.15 37.37 98.78

74246 100.91 100.91 26.89 74.02

74247 112.60 112.60 26.82 85.77

74249 146.13 146.13 35.58 110.55

74250 82.76 82.76 18.42 64.35

74251 135.88 135.88 30.08 105.80

74260 109.50 109.50 18.99 90.51

74261 234.05 234.05 116.77 117.28

74262 320.87 320.87 105.12 215.75

74263 602.23 602.23 87.99 514.24

74270 116.59 116.59 26.13 90.46

Maryland Medical Assistance FS-80

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

74280 140.97 140.97 32.03 108.94

74283 164.80 164.80 79.68 85.12

74290 55.94 55.94 12.67 43.28

74300 39.25 39.25 14.26 24.99

74301 12.50 12.50 12.50

74328 135.72 135.72 27.66 108.06

74329 111.50 111.50 111.50

74330 143.67 143.67 35.53 108.14

74340 100.84 100.84 21.04 79.80

74355 53.37 53.37 53.37

74360 117.29 117.29 21.98 95.31

74363 108.82 108.82 33.09 75.73

74400 87.86 87.86 19.23 68.63

74410 87.25 87.25 18.85 68.40

74415 108.95 108.95 19.18 89.77

74420 103.10 103.10 13.59 89.51

74425 58.37 58.37 13.64 44.73

74430 37.26 37.26 15.50 21.76

74440 64.66 64.66 14.29 50.38

74445 78.36 78.36 42.51 35.85

74450 62.74 62.74 12.85 49.89

74455 69.33 69.33 13.55 55.78

74470 59.54 59.54 20.46 39.08

74485 90.55 90.55 24.76 65.78

74710 37.50 37.50 17.45 20.06

74712 257.09 257.09 142.61 114.48

74713 199.61 199.61 76.49 123.12

74740 59.53 59.53 14.77 44.76

74742 119.28 119.28 24.01 95.27

74775 75.31 75.31 24.34 50.97

75557 315.03 315.03 108.09 206.94

75559 381.75 381.75 138.54 243.25

75561 419.32 419.32 120.18 299.14

75563 528.43 528.43 146.11 382.32

75565 54.32 54.32 11.86 42.46

75571 70.02 70.02 21.89 48.14

75572 225.38 225.38 66.94 158.44

75573 308.66 308.66 101.36 207.30

75574 302.96 302.96 95.31 207.65

75600 196.66 196.66 23.23 173.43

75605 135.88 135.88 53.84 82.06

75625 135.31 135.31 54.39 80.92

75630 166.88 166.88 85.09 81.80

CODE NOTE NFAC FAC 26 TC

75635 344.49 344.49 108.69 235.80

75705 243.83 243.83 109.94 133.89

75710 160.14 160.14 79.25 80.89

75716 184.20 184.20 89.65 94.55

75726 147.11 147.11 53.37 93.74

75731 169.42 169.42 55.20 114.21

75733 183.18 183.18 61.53 121.65

75736 157.87 157.87 53.12 104.75

75741 148.13 148.13 61.04 87.09

75743 165.50 165.50 77.82 87.68

75746 150.97 150.97 54.15 96.82

75756 168.01 168.01 54.62 113.37

75774 85.72 85.72 16.62 69.10

75801 70.50 70.50 70.50

75803 50.50 50.50 50.50

75805 70.50 70.50 70.50

75807 43.50 43.50 43.50

75809 78.77 78.77 18.57 60.20

75810 41.50 41.50 41.50

75820 91.84 91.84 27.09 64.75

75822 108.66 108.66 40.92 67.74

75825 133.54 133.54 54.64 78.90

75827 136.41 136.41 54.48 81.93

75831 138.01 138.01 53.34 84.67

75833 162.37 162.37 70.21 92.16

75840 147.02 147.02 55.68 91.34

75842 176.52 176.52 73.03 103.49

75860 141.50 141.50 53.90 87.60

75870 147.07 147.07 55.70 91.37

75872 153.14 153.14 57.99 95.15

75880 117.07 117.07 31.94 85.13

75885 153.49 153.49 65.63 87.86

75887 155.26 155.26 66.20 89.06

75889 141.41 141.41 52.60 88.82

75891 143.17 143.17 53.57 89.60

75893 117.86 117.86 25.92 91.94

75894 136.50 136.50 55.58 80.92

75898 105.15 105.15 68.96 36.19

75901 141.72 141.72 18.07 123.65

75902 79.06 79.06 20.33 58.73

75956 194.56 194.56 194.56

75957 166.80 166.80 166.80

75958 111.06 111.06 111.06

Maryland Medical Assistance FS-81

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

75959 97.29 97.29 97.29

75970 420.38 420.38 30.86 389.52

75984 88.40 88.40 28.36 60.05

75989 122.15 122.15 57.73 64.42

76000 47.18 47.18 8.51 38.67

76001 121.81 121.81 29.02 92.79

76010 22.03 22.03 7.52 14.50

76080 50.33 50.33 23.48 26.85

76098 16.40 16.40 7.67 8.73

76100 78.85 78.85 26.79 52.05

76101 122.89 122.89 32.57 90.32

76102 153.81 153.81 34.81 119.00

76120 62.66 62.66 11.77 50.89

76125 35.30 35.30 11.06 24.24

76140 10.00 10.00 10.00

76376 22.99 22.99 9.49 13.50

76377 69.92 69.92 38.61 31.31

76380 106.69 106.69 46.47 60.22

76390 364.73 364.73 55.40 309.33

76496 REPORT REPORT REPORT

76497 REPORT REPORT REPORT

76498 REPORT REPORT REPORT

76499 REPORT REPORT REPORT

76506 94.79 94.79 25.14 69.65

76510 133.98 133.98 69.50 64.48

76511 82.49 82.49 42.47 40.02

76512 77.11 77.11 43.57 33.53

76513 75.49 75.49 27.56 47.94

76514 12.01 12.01 7.52 4.49

76516 62.32 62.32 24.04 38.28

76519 67.17 67.17 27.68 39.49

76529 62.55 62.55 25.18 37.37

76536 93.42 93.42 21.82 71.60

76604 70.64 70.64 20.80 49.84

76641 92.82 92.82 30.70 62.12

76642 76.07 76.07 28.67 47.40

76700 102.56 102.56 32.86 69.70

76705 76.71 76.71 24.00 52.71

76706 82.20 82.20 23.49 58.71

76770 98.79 98.79 31.23 67.56

76775 57.58 57.58 28.00 29.58

76776 125.86 125.86 29.48 96.38

76800 94.81 94.81 38.21 56.60

CODE NOTE NFAC FAC 26 TC

76801 101.98 101.98 40.17 61.81

76802 59.63 59.63 38.50 21.13

76805 114.13 114.13 39.50 74.63

76810 76.82 76.82 40.59 36.23

76811 170.09 170.09 89.37 80.72

76812 164.55 164.55 72.52 92.05

76813 100.47 100.47 49.05 51.43

76814 64.61 64.61 40.58 24.03

76815 70.37 70.37 26.49 43.88

76816 93.02 93.02 34.45 58.57

76817 78.03 78.03 29.71 48.32

76818 99.02 99.02 42.72 56.30

76819 78.35 78.35 33.57 44.79

76820 49.76 49.76 26.04 23.72

76821 77.68 77.68 29.43 48.25

76825 223.29 223.29 65.45 157.84

76826 131.43 131.43 32.12 99.31

76827 62.98 62.98 23.40 39.58

76828 46.09 46.09 24.11 21.98

76830 98.06 98.06 27.10 70.96

76831 96.05 96.05 28.81 67.24

76856 88.45 88.45 26.84 61.61

76857 47.50 47.50 23.94 23.56

76870 67.40 67.40 31.10 36.30

76872 100.35 100.35 34.01 66.34

76873 135.83 135.83 59.74 76.09

76881 97.11 97.11 29.38 67.73

76882 28.29 28.29 11.79 16.50

76885 76.59 76.59 28.36 48.23

76886 70.79 70.79 23.42 47.37

76930 77.18 77.18 77.18

76932 74.50 74.50 25.34

76936 217.79 217.79 76.60 141.19

76937 27.36 27.36 12.33 15.03

76940 145.66 145.66 81.15 64.51

76941 125.00 125.00 63.60 61.40

76942 59.14 59.14 31.34 27.80

76945 80.19 80.19 26.87 53.32

76946 32.21 32.21 19.09 13.13

76948 56.77 56.77 27.18 29.59

76965 88.45 88.45 64.29 24.16

76970 62.63 62.63 12.46 50.16

76975 86.08 86.08 33.07 53.01

Maryland Medical Assistance FS-82

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

76977 7.41 7.41 2.77 4.65

76998 143.82 143.82 50.27 93.55

76999 REPORT REPORT REPORT

77001 74.34 74.34 16.06 58.28

77002 74.12 74.12 21.64 52.48

77003 74.82 74.82 23.15 51.68

77011 221.64 221.64 59.89 161.75

77012 121.89 121.89 55.06 66.83

77013 23.34 23.34 23.34

77014 116.82 116.82 42.20 74.62

77021 374.14 374.14 68.36 305.78

77022 25.33 25.33 25.33

77053 58.05 58.05 17.43 40.62

77054 76.65 76.65 22.44 54.21

77058 499.75 499.75 74.71 425.04

77059 499.75 499.75 74.71 425.04

77061 48.19 48.19 25.68 22.51

77062 48.19 48.19 25.68 22.51

77063 48.18 48.18 25.76 22.42

77065 105.85 105.85 30.39 75.46

77066 134.31 134.31 35.79 96.53

77067 108.47 108.47 28.74 79.73

77071 38.53 38.53 38.53

77072 18.24 18.24 7.38 10.86

77073 31.68 31.68 12.45 19.24

77074 52.24 52.24 18.18 34.05

77075 74.71 74.71 22.64 52.07

77076 76.66 76.66 27.57 49.09

77077 37.56 37.56 16.08 21.48

77078 65.61 65.61 10.64 54.97

77080 40.69 40.69 9.61 31.09

77081 26.40 26.40 9.94 16.46

77084 311.45 311.45 75.96 235.49

77085 48.75 48.75 12.65 36.11

77086 30.91 30.91 7.28 23.63

77261 59.26 59.26 59.26

77262 88.00 88.00 88.00

77263 129.13 129.13 129.13

77280 220.28 220.28 27.73 192.55

77285 351.04 351.04 41.42 309.62

77290 414.59 414.59 62.15 352.44

77293 373.68 373.68 79.59 294.09

77295 483.71 483.71 212.30 271.41

CODE NOTE NFAC FAC 26 TC

77299 REPORT REPORT REPORT

77300 61.26 61.26 28.88 32.38

77301 1567.09 1567.09 317.18 1249.91

77306 122.95 122.95 58.07 64.88

77307 239.45 239.45 120.83 118.62

77316 158.57 158.57 59.19 99.38

77317 207.67 207.67 77.17 130.50

77318 298.82 298.82 121.98 176.84

77321 91.45 91.45 47.17 44.28

77331 50.40 50.40 34.88 15.52

77332 64.47 64.47 25.47 39.00

77333 76.81 76.81 29.80 47.02

77334 137.36 137.36 62.28 75.08

77336 64.39 64.39 64.39

77338 428.28 428.28 181.29 246.99

77370 106.68 106.68 106.68

77371 982.06 982.06 982.06

77372 868.46 868.46 868.46

77373 1309.95 1309.95 1309.95

77385 303.99 303.99 60.80

77386 305.05 305.05

77387 52.99 52.99 10.60 42.39

77399 REPORT REPORT REPORT

77401 24.82 24.82 24.82

77402 94.21 94.21 94.21

77407 120.70 120.70 120.70

77412 139.45 139.45 139.45

77417 11.02 11.02 11.02

77423 148.38 148.38 148.38

77424 N.C. N.C.

77425 N.C. N.C.

77427 144.69 144.69 144.69

77431 79.70 79.70 79.70

77432 325.42 325.42 325.42

77435 492.57 492.57 492.57

77469 250.46 250.46

77470 140.46 140.46 107.27 33.19

77499 REPORT REPORT REPORT

77520 944.00 944.00 944.00

77522 944.00 944.00 944.00

77523 1083.90 1083.90 1083.90

77525 1223.79 1223.79 1223.79

77600 332.81 332.81 52.72 280.09

Maryland Medical Assistance FS-83

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

77605 627.43 627.43 82.38 545.05

77610 693.12 693.12 57.46 635.66

77615 825.10 825.10 72.53 752.57

77620 371.99 371.99 66.85 305.14

77750 292.41 292.41 199.69 92.72

77761 309.94 309.94 153.79 156.15

77762 412.57 412.57 231.82 180.75

77763 580.09 580.09 344.92 235.17

77767 196.08 196.08 45.35 150.73

77768 307.59 307.59 60.78 246.81

77770 278.96 278.96 84.02 194.94

77771 519.35 519.35 164.63 354.72

77772 793.10 793.10 233.01 560.09

77778 649.51 649.51 349.05 300.46

77789 94.10 94.10 45.15 48.95

77790 14.91 14.91 8.99 5.92

77799 REPORT REPORT REPORT

78012 72.10 72.10 7.91 64.19

78013 158.80 158.80 14.12 144.68

78014 210.79 210.79 20.09 190.70

78015 183.96 183.96 25.57 158.39

78016 235.47 235.47 26.30 209.17

78018 259.73 259.73 31.89 227.84

78020 68.88 68.88 21.48 47.40

78070 248.98 248.98 30.25 218.73

78071 313.40 313.40 48.20 265.20

78072 340.81 340.81 59.34 281.47

78075 369.16 369.16 28.39 340.73

78099 REPORT REPORT REPORT

78102 141.12 141.12 20.58 120.54

78103 181.78 181.78 27.58 154.20

78104 203.10 203.10 29.75 173.35

78110 83.01 83.01 7.70 75.31

78111 81.04 81.04 9.22 71.83

78120 77.81 77.81 9.34 68.47

78121 90.14 90.14 13.19 76.95

78122 98.64 98.64 20.45 78.19

78130 138.43 138.43 23.89 114.54

78135 289.80 289.80 25.01 264.79

78140 127.39 127.39 26.66 100.73

78185 175.56 175.56 15.99 159.57

78191 171.95 171.95 29.68 142.27

78195 295.12 295.12 45.60 249.52

CODE NOTE NFAC FAC 26 TC

78199 REPORT REPORT REPORT

78201 156.68 156.68 16.28 140.40

78202 165.95 165.95 18.24 147.71

78205 197.35 197.35 29.19 168.16

78206 283.81 283.81 36.07 247.74

78215 161.18 161.18 18.83 142.35

78216 116.80 116.80 23.78 93.02

78226 285.26 285.26 29.44 255.82

78227 372.89 372.89 34.68 338.21

78230 145.01 145.01 17.87 127.14

78231 109.73 109.73 21.19 88.54

78232 113.67 113.67 20.77 92.90

78258 186.40 186.40 28.41 157.99

78261 203.55 203.55 26.91 176.64

78262 201.00 201.00 25.73 175.27

78264 279.25 279.25 30.02 249.23

78265 330.32 330.32 39.34 290.95

78266 427.93 427.93 45.02 382.91

78267 8.79 8.79 8.79

78268 75.06 75.06 75.06

78270 84.13 84.13 8.11 76.02

78271 74.44 74.44 8.01 66.43

78272 81.15 81.15 10.94 70.21

78278 288.88 288.88 37.84 251.04

78282 25.00 25.00 25.00

78290 275.75 275.75 26.00 249.75

78291 211.82 211.82 32.90 178.92

78299 REPORT REPORT REPORT

78300 150.14 150.14 19.08 131.06

78305 191.96 191.96 26.30 165.66

78306 208.11 208.11 27.32 180.79

78315 286.83 286.83 38.69 248.14

78320 209.08 209.08 43.18 165.88

78350 28.11 28.11 9.09 19.02

78351 N.C. N.C.

78399 REPORT REPORT REPORT

78414 80.61 80.61 17.17 63.44

78428 149.51 149.51 28.89 120.62

78445 150.64 150.64 18.65 131.99

78451 280.49 280.49 51.81 228.68

78452 390.12 390.12 60.90 329.22

78453 251.24 251.24 38.09 213.15

78454 361.58 361.58 51.49 310.09

Maryland Medical Assistance FS-84

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

78456 264.60 264.60 38.74 225.86

78457 144.97 144.97 26.63 118.35

78458 169.03 169.03 35.02 134.01

78459 958.76 958.76 52.16 906.60

78466 161.66 161.66 27.01 134.65

78468 171.84 171.84 32.32 139.52

78469 207.84 207.84 38.22 169.62

78472 210.69 210.69 41.59 169.10

78473 296.13 296.13 68.35 227.78

78481 191.68 191.68 49.30 142.38

78483 246.88 246.88 68.41 178.47

78491 1068.50 1068.50 54.92 1013.58

78492 1118.57 1118.57 67.11 1051.46

78494 243.73 243.73 59.03 184.70

78496 43.92 43.92 23.36 20.57

78499 REPORT REPORT REPORT

78579 154.27 154.27 18.42 135.85

78580 198.08 198.08 28.40 169.68

78582 279.03 279.03 41.24 237.79

78597 170.27 170.27 27.84 142.45

78598 262.17 262.17 33.03 229.14

78599 REPORT REPORT REPORT

78600 153.86 153.86 17.31 136.55

78601 178.24 178.24 19.39 158.85

78605 166.23 166.23 20.91 145.32

78606 274.08 274.08 24.28 249.80

78607 291.03 291.03 45.90 245.13

78608 1104.73 1104.73 53.69 1051.04

78609 57.72 57.72 57.72

78610 145.54 145.54 11.77 133.78

78630 281.46 281.46 26.23 255.23

78635 284.43 284.43 24.32 260.11

78645 269.65 269.65 21.49 248.16

78647 293.93 293.93 35.54 258.39

78650 275.28 275.28 23.56 251.72

78660 148.85 148.85 20.08 128.77

78699 REPORT REPORT REPORT

78700 142.12 142.12 17.07 125.05

78701 175.40 175.40 18.24 157.16

78707 192.28 192.28 36.01 156.29

78708 162.52 162.52 51.67 110.85

78709 301.56 301.56 52.59 248.97

78710 195.95 195.95 26.96 168.99

CODE NOTE NFAC FAC 26 TC

78725 88.10 88.10 14.10 74.00

78730 59.49 59.49 5.78 53.71

78740 181.51 181.51 21.29 160.22

78761 176.76 176.76 27.96 148.80

78799 REPORT REPORT REPORT

78800 159.54 159.54 26.31 133.22

78801 217.76 217.76 31.01 186.75

78802 268.57 268.57 32.15 236.42

78803 282.99 282.99 39.90 243.09

78804 470.40 470.40 40.22 430.18

78805 151.35 151.35 27.83 123.52

78806 276.55 276.55 32.36 244.19

78807 283.56 283.56 40.18 243.38

78808 36.25 36.25 36.25

78811 963.89 963.89 56.58 907.31

78812 1121.94 1121.94 69.90 1052.04

78813 1124.98 1124.98 72.22 1052.76

78814 1133.51 1133.51 80.48 1053.03

78815 1150.00 1150.00 89.82 1060.19

78816 1350.00 1350.00 106.52 1243.49

78999 REPORT REPORT REPORT

79005 126.64 126.64 79.86 46.78

79101 136.25 136.25 89.27 46.98

79200 138.29 138.29 83.79 54.50

79300 43.85 43.85 43.85

79403 182.87 182.87 101.91 80.96

79440 132.66 132.66 87.02 45.64

79445 91.38 91.38 91.38

79999 REPORT REPORT REPORT

90281 INVOICE INVOICE REPORT

90283 INVOICE INVOICE REPORT

90284 INVOICE INVOICE REPORT

90287 INVOICE INVOICE REPORT

90288 INVOICE INVOICE REPORT

90291 INVOICE INVOICE REPORT

90296 INVOICE INVOICE REPORT

90375 314.27 314.27

90376 317.43 317.43

90378 INVOICE INVOICE REPORT

90384 38.75 38.75

90385 25.43 25.43

90386 INVOICE INVOICE REPORT

90389 114.00 114.00

Maryland Medical Assistance FS-85

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

90393 INVOICE INVOICE REPORT

90396 110.41 110.41

90399 INVOICE INVOICE REPORT

90460 N.C. N.C.

90461 N.C. N.C.

90471 N.C. N.C.

90472 N.C. N.C.

90473 N.C. N.C.

90474 N.C. N.C.

90476 INVOICE INVOICE REPORT

90477 INVOICE INVOICE REPORT

90581 INVOICE INVOICE REPORT

90585 131.25 131.25

90586 131.25 131.25

90620 160.75 160.75

90621 115.75 115.75

90625 N.C. N.C.

90630 20.34

90632 53.39 53.39

90633 21.17 21.17

90634 23.91 23.91

90636 78.16 78.16

90644 INVOICE INVOICE REPORT

90647 20.37 20.37 20.37

90648 22.83 22.83 22.83

90649 130.27 130.27

90650 128.75 128.75

90651 177.70

90653 50.22

90654 N.C. N.C.

90655 15.45 15.45

90656 19.25 19.25

90657 5.68 5.68 5.68

90658 11.37 11.37 11.37

90660 22.32 22.32

90661 INVOICE INVOICE REPORT

90662 49.03 49.03

90664 N.C. N.C.

90666 INVOICE INVOICE REPORT

90667 INVOICE INVOICE REPORT

90668 INVOICE INVOICE REPORT

90670 192.64 192.64

90672 26.88 26.88

CODE NOTE NFAC FAC 26 TC

90673 40.61

90674 24.05

90675 269.12 269.12

90676 146.00 146.00

90680 63.25 63.25

90681 63.25 63.25

90682 46.31

90685 21.20 21.20

90686 19.03 19.03

90687 9.40

90688 17.84 17.84

90690 7.00 7.00

90691 82.16 82.16

90696 48.00 48.00

90698 70.72 70.72

90700 15.30 15.30 15.30

90702 30.81 30.81 30.81

90707 47.01 47.01 47.01

90710 117.50 117.50

90713 28.01 28.01

90714 22.07 22.07

90715 31.67 31.67

90716 81.75 81.75 81.75

90717 59.49 59.49

90723 60.06 60.06 60.06

90732 98.85 98.85

90733 100.43 100.43 100.43

90734 82.00 82.00

90736 212.00 212.00

90738 INVOICE INVOICE REPORT

90739 N.C. N.C.

90740 126.60 126.60

90743 26.13 26.13 26.13

90744 26.14 26.14 26.14

90746 63.30 63.30

90747 126.60 126.60

90748 45.32 45.32

90749 INVOICE INVOICE REPORT

90750 140.00

90756 22.79 22.79

90785 N.C. N.C.

90791 146.63 146.63

90792 154.19 154.19

Maryland Medical Assistance FS-86

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

90832 66.72 66.72

90833 68.89 68.89

90834 88.29 88.29

90836 87.91 87.91

90837 132.66 132.66

90838 115.06 115.06

90839 138.62 138.62

90840 66.00 66.00

90845 62.44 60.90

90846 106.96 104.98

90847 111.49 106.51

90849 37.55 33.83 37.55

90853 23.93 23.93

90863 N.C. N.C.

90865 115.98 100.79 115.98

90867 159.53 96.34

90868 146.32 18.54

90869 399.60 95.62

90870 105.39 65.10 105.39

90875 52.15 43.28 52.15

90876 78.65 68.48 78.65

90880 83.23 74.86

90882 N.C. N.C.

90885 N.C. N.C.

90887 N.C. N.C.

90889 N.C. N.C.

90899 20.00 20.00

90901 28.53 14.87 28.53

90911 70.23 33.95 70.23

90935 55.63 55.63

90937 80.32 80.32

90940 15.00 15.00

90945 66.34 66.34

90947 95.52 95.52

90951 728.23 728.23

90952 473.88 473.88

90953 316.07 316.07

90954 629.10 629.10

90955 353.87 353.87

90956 246.02 246.02

90957 497.16 497.16

90958 336.55 336.55

90959 229.01 229.01

CODE NOTE NFAC FAC 26 TC

90960 219.29 219.29

90961 184.37 184.37

90962 142.32 142.32

90963 420.63 420.63

90964 368.06 368.06

90965 350.24 350.24

90966 183.76 183.76

90967 14.98 14.98

90968 12.04 12.04

90969 11.78 11.78

90970 6.04 6.04

90989 N.C. N.C.

90993 N.C. N.C.

90997 69.34 69.34

90999 REPORT REPORT REPORT

91010 154.68 154.68 57.37 97.31

91013 19.39 19.39 7.10 12.29

91020 185.10 185.10 57.49 127.61

91022 151.42 151.42 65.69 85.73

91030 106.48 106.48 36.17 70.31

91034 167.00 167.00 44.07 122.93

91035 383.65 383.65 64.95 318.70

91037 127.20 127.20 38.83 88.37

91038 358.71 358.71 44.59 314.12

91040 341.50 341.50 35.89 305.61

91065 59.83 59.83 8.17 51.66

91110 732.83 732.83 107.43 625.47

91111 596.28 596.28 40.43 555.85

91112 1031.58 1031.58 101.40 930.18

91117 117.58 117.58

91120 340.76 340.76 38.68 302.08

91122 189.84 189.84 73.05 116.79

91132 117.69 117.69 20.47 97.22

91133 137.12 137.12 26.45 110.67

91200 31.28 31.28 10.67 20.61

91299 REPORT REPORT REPORT

92002 63.71 37.20

92004 116.51 77.46

92012 67.09 41.15

92014 96.99 62.22

92015 19.02 15.03 19.02

92018 113.05 113.05 113.05

92019 56.16 56.16

Maryland Medical Assistance FS-87

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

92020 21.00 16.43 21.00

92025 29.90 29.90 15.47 14.43

92060 51.21 51.21 29.80 21.41

92065 P 42.98 42.98 13.88 29.10

92071 31.59 28.03

92072 104.54 80.01

92081 33.37 33.37 15.65 17.72

92082 49.38 49.38 21.83 27.56

92083 56.74 56.74 24.05 32.69

92100 63.33 34.29 63.33

92132 30.41 30.41 15.73 14.68

92133 37.09 37.09 21.79 15.29

92134 37.09 37.09 22.90 14.20

92136 71.45 71.45 27.84 43.61

92145 14.29 14.29 7.56 6.73

92225 20.98 16.70 20.98

92226 19.36 14.80 19.36

92227 11.72 11.72

92228 27.30 27.30 16.21 11.09

92230 48.27 25.48 48.27

92235 84.00 84.00 41.84 42.17

92240 165.90 165.90 36.00 129.90

92242 198.27 198.27 46.30 151.97

92250 53.55 53.55 19.97 33.58

92260 14.48 8.49 14.48

92265 67.22 67.22 35.34 31.88

92270 72.39 72.39 31.29 41.10

92275 117.90 117.90 41.81 76.09

92283 44.78 44.78 7.23 37.55

92284 51.16 51.16 10.01 41.15

92285 30.13 30.13 4.52 25.61

92286 93.71 93.71 53.17 40.54

92287 109.44 109.44 36.04 73.39

92310 P 75.28 46.21

92311 P 79.33 43.13

92312 P 92.38 49.91

92313 P 75.89 36.56

92314 62.97 27.34 62.97

92315 P 58.79 17.17 58.79

92316 P 73.46 26.27 73.46

92317 60.25 17.78

92325 P 33.95 33.95

92326 P 36.82 36.82

CODE NOTE NFAC FAC 26 TC

92340 27.88 14.48

92341 31.71 18.60

92342 34.16 20.77

92352 N.C. N.C.

92353 N.C. N.C.

92354 P 61.53 61.53

92355 P 43.11 43.11

92358 N.C. N.C.

92370 24.26 12.58

92371 N.C. N.C.

92499 REPORT REPORT REPORT

92502 87.78 87.78 87.78

92504 26.23 8.75 26.23

92507 63.99 61.27

92508 30.47 30.47 30.47

92511 109.20 36.98 109.20

92512 58.49 24.76 58.49

92516 59.85 20.81

92520 60.04 36.50

92521 91.35 91.35

92522 74.00 74.00

92523 153.97 153.97

92524 77.40 77.40

92526 80.85 66.90 80.85

92531 3.50 3.50 3.50

92532 3.50 3.50 3.50

92533 3.50 3.50 3.50

92534 3.50 3.50 3.50

92537 34.43 34.43 26.67 7.77

92538 17.54 17.54 13.21 4.33

92540 87.06 87.06 67.69 19.37

92541 23.93 23.93 20.34 3.59

92542 26.97 26.97 23.77 3.20

92544 16.44 16.44 13.90 2.53

92545 14.72 14.72 12.30 2.42

92546 82.40 82.40 11.54 70.86

92547 4.97 4.97 4.97

92548 95.38 95.38 24.46 70.93

92550 35.00 35.00

92551 9.72 9.72 9.72

92552 25.40 25.40 25.40

92553 30.25 30.25 30.25

92555 18.85 18.85 18.85

Maryland Medical Assistance FS-88

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

92556 30.53 30.53 30.53

92557 36.60 31.64 36.60

92558 N.C. N.C.

92559 N.C. N.C.

92560 5.50 5.50 5.50

92561 31.14 31.14 31.14

92562 37.37 37.37 37.37

92563 24.83 24.83 24.83

92564 21.98 21.98 21.98

92565 13.22 13.22 13.22

92567 20.00 14.98 20.00

92568 16.22 16.22 16.22

92570 50.00 47.04

92571 21.98 21.98

92572 25.44 25.44

92575 47.10 47.10

92576 29.39 29.39

92577 15.26 15.26

92579 35.55 33.46 35.55

92582 53.94 53.94

92583 40.51 40.51 40.51

92584 70.26 70.26 70.26

92585 140.00 140.00 26.82 113.19

92586 70.00 70.00

92587 20.86 20.86 17.62 3.24

92588 32.12 32.12 28.12 4.00

92590 13.00 13.00 13.00

92591 13.00 13.00 13.00

92592 5.50 5.50 5.50

92593 35.00 35.00

92594 11.00 11.00 11.00

92595 13.00 13.00 13.00

92596 33.42 33.42 33.42

92597 69.92 56.29 69.92

92601 138.69 117.22

92602 80.14 63.86

92603 118.62 100.67

92604 70.49 59.17

92605 72.29 68.87

92606 64.61 55.21

92607 121.74 121.74

92608 41.53 41.53

92609 86.26 86.26

CODE NOTE NFAC FAC 26 TC

92610 81.43 72.41

92611 88.58 88.58

92612 149.99 62.07

92613 29.94 29.94

92614 134.84 62.07

92615 26.03 26.03

92616 186.01 92.02

92617 32.60 32.60

92618 N.C. N.C.

92620 73.76 64.35 73.76

92621 17.33 14.76 17.33

92625 55.00 48.74 55.00

92626 70.21 64.22 70.21

92627 17.37 15.45 17.37

92630 N.C. N.C.

92633 N.C. N.C.

92640 86.98 74.44

92700 REPORT REPORT REPORT

92920 461.79 461.79

92921 N.C. N.C.

92924 549.06 549.06

92925 N.C. N.C.

92928 512.97 512.97

92929 N.C. N.C.

92933 573.62 573.62

92934 N.C. N.C.

92937 512.40 512.40

92938 N.C. N.C.

92941 574.80 574.80

92943 574.80 574.80

92944 N.C. N.C.

92950 239.13 146.23 239.13

92953 1.08 1.08 1.08

92960 154.87 100.82 154.87

92961 201.34 201.34 201.34

92970 147.77 147.77

92971 81.66 81.66

92973 143.29 143.29

92974 131.41 131.41

92975 305.51 305.51 305.51

92977 69.80 69.80 69.80

92978 236.66 236.66 77.17 159.49

92979 61.00 61.00 61.00

Maryland Medical Assistance FS-89

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

92986 1070.11 1070.11

92987 1104.20 1104.20

92990 881.37 881.37

92992 1200.57 1200.57 1200.57

92993 1200.57 1200.57 1200.57

92997 523.02 523.02 523.02

92998 258.15 258.15

93000 17.58 17.58 17.58

93005 8.54 8.54 8.54

93010 6.56 6.56 6.56

93015 80.32 80.32 80.32

93016 17.80 17.80 17.80

93017 39.34 39.34 39.34

93018 11.96 11.96 11.96

93024 91.37 91.37 45.79 45.58

93025 161.26 161.26 35.36 125.90

93040 10.46 10.46 10.46

93041 4.75 4.75 4.75

93042 5.72 5.72 5.72

93050 15.31 15.31 7.63 7.68

93224 90.29 90.29 90.29

93225 26.60 26.60 26.60

93226 37.93 37.93 37.93

93227 20.75 20.75 20.75

93228 20.22 20.22

93229 579.09 579.09

93260 56.07 56.07 36.71 19.36

93261 51.30 51.30 32.15 19.16

93268 217.68 217.68 217.68

93270 9.25 9.25 9.25

93271 149.51 149.52

93272 20.29 20.29 20.29

93278 29.94 29.94 11.93 18.01

93279 42.51 42.51 27.48 15.03

93280 50.17 50.17 32.63 17.55

93281 58.66 58.66 39.39 19.26

93282 54.27 54.27 37.42 16.85

93283 66.03 66.03 48.42 17.61

93284 77.23 77.23 56.69 20.54

93285 36.81 36.81 22.42 14.39

93286 21.45 21.45 10.60 10.85

93287 28.90 28.90 17.35 11.55

93288 32.99 32.99 18.10 14.89

CODE NOTE NFAC FAC 26 TC

93289 51.41 51.41 34.88 16.53

93290 24.66 24.66 14.43 10.23

93291 31.61 31.61 17.29 14.31

93292 28.53 28.53 16.42 12.11

93293 46.01 46.01 12.68 33.34

93294 27.70 27.70

93295 52.61 52.61

93296 28.17 28.17

93297 20.50 20.50

93298 22.28 22.28

93299 34.06 34.06

93303 188.47 188.47 48.21 140.26

93304 123.85 123.85 27.31 96.54

93306 205.69 205.69 69.93 135.76

93307 127.94 127.94 39.32 88.62

93308 99.71 99.71 23.46 76.25

93312 243.16 243.16 104.87 138.29

93313 11.16 11.16 11.16

93314 210.92 210.92 79.26 131.66

93315 333.24 333.24 99.87 233.37

93316 26.07 26.07 26.07

93317 314.59 314.59 72.83 241.76

93318 56.00 56.00 56.00

93320 53.32 53.32 17.47 35.86

93321 26.96 26.96 7.05 19.91

93325 25.33 25.33 2.99 22.35

93350 191.29 191.29 63.68 127.61

93351 215.33 215.33 76.23 139.10

93352 29.64 29.64

93355 190.44 190.44 190.44

93451 646.25 646.25 116.45 529.80

93452 715.24 715.24 207.28 507.96

93453 935.91 935.91 279.56 656.35

93454 737.74 737.74 212.99 524.75

93455 860.78 860.78 247.90 612.88

93456 933.94 933.94 277.38 656.56

93457 1051.49 1051.49 310.40 741.09

93458 890.17 890.17 263.58 626.59

93459 982.82 982.82 297.89 684.93

93460 1051.49 1051.49 331.22 720.27

93461 1205.26 1205.26 366.04 839.22

93462 169.63 169.63

93463 89.16 89.16

Maryland Medical Assistance FS-90

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

93464 212.10 212.10 70.67 141.43

93503 100.57 100.57 100.57

93505 560.71 560.71 175.50 385.21

93530 331.00 331.00 331.00

93531 1883.34 1883.34 342.39 1540.95

93532 855.00 855.00 855.00

93533 754.00 754.00 754.00

93561 59.61 59.61 12.00 47.61

93562 16.00 16.00 1.18 14.82

93563 47.12 47.12

93564 49.83 49.83

93565 36.58 36.58

93566 142.68 37.55

93567 117.32 42.58

93568 128.76 38.36

93571 231.84 231.84 77.18 154.66

93572 133.35 133.35 62.06 71.29

93580 791.91 791.91

93581 1088.83 1088.83

93582 560.13 560.13

93583 623.39 623.39

93590 1060.35 1060.35

93591 880.14 880.14

93592 387.74 387.74

93600 158.09 158.09 96.20 61.89

93602 57.84 57.84 57.84

93603 57.82 57.82 57.82

93609 149.00 149.00 149.00

93610 179.51 179.51 132.51 47.00

93612 81.95 81.95 81.95

93613 322.72 322.72 322.72

93615 25.00 25.00 25.00

93616 45.45 45.45 45.45

93618 303.51 303.51 179.25 124.26

93619 320.00 320.00 320.00

93620 899.47 899.47 508.47 391.00

93621 100.00 100.00 100.00

93622 300.00 300.00 300.00 300.00

93623 77.59 77.59 77.59

93624 265.07 265.07 197.00 68.07

93631 204.79 204.79 204.79

93640 244.83 244.83 144.87 99.96

93641 377.63 377.63 252.90 124.73

CODE NOTE NFAC FAC 26 TC

93642 276.39 276.39 208.98 67.41

93644 212.16 212.16 154.07 58.09

93650 479.79 479.79 479.79

93653 698.71 698.71

93654 932.50 932.50

93655 349.34 349.34

93656 932.76 932.76

93657 349.66 349.66

93660 129.75 129.75 74.90 54.86

93662 236.31 236.31 111.42 124.89

93668 15.43 15.43

93701 24.47 24.47 5.42 19.05

93702 100.25 100.25 100.25

93724 267.68 267.68 238.13 29.55

93740 8.11 8.11 8.11

93745 66.22 66.22 16.51 49.67

93750 N.C. N.C.

93770 6.29 6.29 6.29

93784 53.92 53.92

93786 25.89 25.89

93788 5.36 5.36

93790 14.42 14.42

93797 14.60 7.47 14.60

93798 21.58 11.36 21.58

93799 REPORT REPORT REPORT

93880 162.13 162.13 40.61 121.52

93882 130.93 130.93 24.76 106.17

93886 216.03 216.03 60.73 155.30

93888 109.86 109.86 19.58 90.28

93890 219.29 219.29 38.97 180.32

93892 136.42 136.42 45.47 90.95

93893 136.06 136.06 45.10 90.97

93895 N.C. N.C.

93922 96.77 96.77 13.51 83.26

93923 148.12 148.12 23.31 124.81

93924 180.45 180.45 25.32 155.13

93925 207.69 207.69 30.53 177.16

93926 108.47 108.47 18.20 90.27

93930 166.72 166.72 41.81 124.91

93931 103.02 103.02 18.89 84.13

93970 158.01 158.01 26.77 131.24

93971 96.20 96.20 17.37 78.83

93975 224.54 224.54 44.53 180.01

Maryland Medical Assistance FS-91

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

93976 161.85 161.85 40.07 121.78

93978 152.80 152.80 38.00 114.80

93979 95.93 95.93 19.19 76.74

93980 119.11 119.11 57.10 62.01

93981 73.18 73.18 20.14 53.04

93990 108.86 108.86 18.62 90.24

93998 N.C. N.C.

94002 71.77 71.77

94003 51.96 51.96

94004 38.30 38.30

94005 N.C. N.C.

94010 28.53 28.53 6.50 22.03

94011 75.84 75.84

94012 116.54 116.54

94013 19.35 19.35

94014 44.72 44.72 44.72

94015 25.11 25.11 25.11

94016 19.61 19.61 19.61

94060 48.58 48.58 10.09 38.49

94070 47.46 47.46 22.10 25.36

94150 20.18 20.18 3.04 17.14

94200 20.67 20.67 4.11 16.55

94250 21.24 21.24 4.12 17.12

94375 31.40 31.40 11.32 20.08

94400 45.24 45.24 15.01 30.23

94450 55.21 55.21 15.03 40.19

94452 45.94 45.94 11.08 34.86

94453 63.76 63.76 14.66 49.10

94610 46.19 46.19

94617 83.46 83.46 28.50 54.96

94618 29.58 29.58 19.49 10.09

94621 128.70 128.70 52.51 76.19

94640 14.85 14.85

94642 24.70 24.70 24.70

94644 35.66 35.66

94645 11.72 11.72

94660 50.08 29.85 50.08

94662 27.32 27.32 27.32

94664 14.00 14.00 14.00

94667 21.45 21.45

94668 N.C. N.C.

94669 29.40 29.40

94680 51.93 51.93 10.87 41.06

CODE NOTE NFAC FAC 26 TC

94681 53.78 53.78 9.31 44.47

94690 48.36 48.36 3.29 45.07

94726 46.50 46.50 10.06 36.44

94727 36.38 36.38 9.84 26.54

94728 36.38 36.38 10.84 25.54

94729 46.34 46.34 7.50 38.84

94750 63.19 63.19 8.06 55.13

94760 2.60 2.60

94761 4.55 4.55

94762 21.75 21.75

94770 7.13 7.13

94772 171.00 171.00

94774 REPORT REPORT REPORT

94775 REPORT REPORT REPORT

94776 REPORT REPORT REPORT

94777 30.00 30.00

94780 47.08 19.66

94781 18.24 6.84

94799 20.00 20.00

95004 5.43 5.43 5.43

95012 15.43 15.43

95017 7.61 3.16

95018 18.75 6.80

95024 6.29 1.08 6.29

95027 4.31 4.31

95028 10.87 10.87 10.87

95044 5.88 5.88 5.88

95052 6.50 6.50 6.50

95056 35.66 35.66 35.66

95060 28.53 28.53 28.53

95065 20.27 20.27 20.27

95070 30.89 30.89

95071 36.56 36.56

95076 99.38 59.93

95079 69.34 55.10

95115 8.89 8.89 8.89

95117 10.31 10.31 10.31

95120 6.50 6.50 6.50

95125 6.50 6.50 6.50

95130 6.50 6.50 6.50

95131 6.50 6.50 6.50

95132 6.50 6.50 6.50

95133 6.50 6.50 6.50

Maryland Medical Assistance FS-92

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

95134 6.50 6.50 6.50

95144 10.47 2.49 10.47

95145 20.16 2.49 20.16

95146 36.98 2.49 36.98

95147 39.25 2.49 39.25

95148 55.50 2.49 55.50

95149 73.46 2.49 73.46

95165 10.47 2.49 10.47

95170 7.62 2.49 7.62

95180 110.50 79.49 110.50

95199 REPORT REPORT REPORT

95249 49.06 49.06

95250 126.98 126.98 126.98

95251 33.91 33.91 33.91

95782 907.45 907.45 120.51 786.94

95783 968.56 968.56 131.43 837.13

95800 173.25 173.25 49.58 123.67

95801 80.78 80.78 43.11 37.66

95803 111.91 111.91 33.44 78.47

95805 420.39 420.39 55.58 364.81

95806 160.52 160.52 56.34 104.18

95807 414.95 414.95 54.19 360.76

95808 512.60 512.60 62.74 449.86

95810 628.08 628.08 118.14 509.94

95811 690.50 690.50 128.78 561.72

95812 259.03 259.03 45.23 213.78

95813 325.97 325.97 67.90 258.07

95816 289.28 289.28 44.75 244.53

95819 332.92 332.92 44.28 288.64

95822 300.40 300.40 44.37 256.03

95824 25.00 25.00 25.00

95827 533.55 533.55 46.58 486.97

95829 1533.12 1533.12 264.77 1268.35

95830 173.96 71.64 173.96

95831 24.98 12.44 24.98

95832 24.72 13.32 24.72

95833 29.11 18.20 29.11

95834 41.19 24.38 41.19

95851 14.27 6.26 14.27

95852 12.37 4.47 12.37

95857 42.75 23.37 42.75

95860 96.98 96.98 40.08 56.90

95861 137.67 137.67 64.22 73.45

CODE NOTE NFAC FAC 26 TC

95863 172.95 172.95 76.22 96.73

95864 194.75 194.75 81.83 112.92

95865 115.70 115.70 65.07 50.63

95866 107.33 107.33 52.74 54.59

95867 76.78 76.78 31.46 45.32

95868 106.65 106.65 48.84 57.81

95869 73.23 73.23 15.23 58.00

95870 74.08 74.08 15.17 58.91

95872 154.24 154.24 120.28 33.96

95873 58.33 58.33 15.45 42.88

95874 58.94 58.94 15.35 43.59

95875 92.79 92.79 41.39 51.40

95885 48.08 48.08 15.07 33.01

95886 72.05 72.05 35.90 36.15

95887 66.68 66.68 30.99 35.69

95905 66.20 66.20 2.53 63.67

95907 80.77 80.77 43.66 37.11

95908 99.61 99.61 52.44 47.17

95909 119.38 119.38 62.84 56.54

95910 157.09 157.09 83.85 73.22

95911 185.56 185.56 103.69 81.87

95912 222.43 222.43 133.24 89.19

95913 257.66 257.66 158.59 99.07

95921 67.16 67.16 35.84 31.32

95922 79.02 79.02 38.53 40.50

95923 112.23 112.23 38.83 73.40

95924 125.77 125.77 73.29 52.48

95925 110.89 110.89 22.58 88.31

95926 107.47 107.47 22.00 85.46

95927 110.31 110.31 21.51 88.79

95928 169.64 169.64 62.41 107.21

95929 174.73 174.73 63.08 111.65

95930 103.76 103.76 27.45 76.31

95933 60.87 60.87 24.10 36.77

95937 65.04 65.04 26.72 38.32

95938 274.84 274.84 35.84 239.00

95939 403.32 403.32 93.05 310.27

95940 26.85 26.85

95941 N.C. N.C.

95943 74.79 74.79 37.46 37.33

95950 266.30 266.30 60.85 205.45

95951 450.00 450.00 76.14 373.86

95953 336.95 336.95 125.21 211.74

Maryland Medical Assistance FS-93

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

95954 361.19 361.19 99.47 261.72

95955 170.74 170.74 41.95 128.79

95956 1307.69 1307.69 152.74 1154.95

95957 243.01 243.01 86.17 156.84

95958 461.48 461.48 177.35 284.13

95961 242.83 242.83 127.41 115.42

95962 206.60 206.60 135.26 71.34

95965 705.99 705.99 329.63 376.36

95966 104.33 104.33 104.33

95967 329.98 329.98 149.51

95970 54.30 18.96 54.30

95971 40.18 31.84 40.18

95972 56.89 40.61 56.89

95974 163.57 129.09 163.57

95975 87.68 72.86 87.68

95978 196.48 151.15 196.48

95979 84.94 70.40 84.94

95980 36.73 36.73

95981 25.51 14.12

95982 41.85 28.74

95990 73.08 73.08

95991 94.81 30.97 94.81

95992 33.50 28.93

95999 20.00 20.00

96000 74.26 74.26 74.26

96001 96.15 96.15 96.15

96002 17.01 17.01 17.01

96003 12.84 12.84 12.84

96004 91.47 91.47 91.47

96020 271.88 271.88 124.79 147.09

96040 38.02 38.02

96101 75.59 74.88 75.59

96102 49.04 22.68 49.04

96103 N.C. N.C.

96105 83.58 83.58 83.58

96110 8.86 8.86 8.86

96111 101.32 96.47 101.32

96116 71.54 69.55

96118 84.35 68.31 84.35

96119 N.C. N.C.

96120 N.C. N.C.

96125 N.C. N.C.

96127 4.71 4.71 4.71

CODE NOTE NFAC FAC 26 TC

96150 18.12 17.80

96151 17.53 17.22

96152 5.72 5.61

96153 N.C. N.C.

96154 N.C. N.C.

96155 N.C. N.C.

96160 4.06 4.06

96161 4.06 4.06

96360 46.99 46.99

96361 14.10 14.10

96365 57.37 57.37

96366 18.15 18.15

96367 29.45 29.45

96368 16.97 16.97

96369 143.07 143.07

96370 12.18 12.18

96371 55.67 55.67

96372 20.24 20.24

96373 15.11 15.11

96374 45.98 45.98

96375 19.74 19.74

96376 10.90 10.90

96377 REPORT REPORT REPORT

96379 REPORT REPORT REPORT

96401 59.64 59.64 59.64

96402 31.57 31.57 31.57

96405 87.31 23.64 87.31

96406 119.14 36.29 119.14

96409 92.78 92.78 92.78

96411 52.92 52.92 52.92

96413 125.73 125.73 125.73

96415 27.91 27.91 27.91

96416 136.57 136.57 136.57

96417 61.84 61.84 61.84

96420 87.47 87.47 87.47

96422 148.83 148.83 148.83

96423 62.56 62.56 62.56

96425 147.47 147.47 147.47

96440 625.06 100.45 625.06

96446 163.61 23.67

96450 178.55 75.13 178.55

96521 112.44 112.44 112.44

96522 91.67 91.67 91.67

Maryland Medical Assistance FS-94

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

96523 21.36 21.36 21.36

96542 136.18 36.63 136.18

96549 REPORT REPORT REPORT

96567 108.95 108.95

96570 45.07 45.07

96571 20.48 20.48

96573 167.47 167.47

96574 215.07 215.07

96900 16.85 16.85 16.85

96902 16.68 16.11 16.68

96904 56.86 56.86

96910 57.32 57.32 57.32

96912 73.57 73.57 73.57

96913 104.43 104.43 104.43

96920 123.73 52.76

96921 136.30 59.64

96922 187.66 95.59

96931 127.46 127.46

96932 22.84 22.84

96933 35.40 35.40

96934 65.13 65.13

96935 27.97 27.97

96936 33.77 33.77

96999 REPORT REPORT REPORT

97010 4.77 4.77 4.77

97012 12.67 12.67 12.67

97014 12.52 12.52 12.52

97016 15.37 15.37 15.37

97018 8.76 8.76 8.76

97022 18.81 18.81 18.81

97024 5.34 5.34 5.34

97026 4.77 4.77 4.77

97028 5.87 5.87 5.87

97032 14.96 14.96 14.96

97033 17.48 17.48 17.48

97034 14.17 14.17 14.17

97035 9.90 9.90 9.90

97036 26.01 26.01 26.01

97039 9.90 9.90 9.90

97110 29.03 29.03 29.03

97112 26.58 26.58 26.58

97113 33.98 33.98 33.98

97116 22.08 22.08 22.08

CODE NOTE NFAC FAC 26 TC

97124 20.46 20.46 20.46

97139 13.38 13.38 13.38

97140 23.45 23.45

97150 18.25 18.25 18.25

97161 69.20 69.20

97162 69.20 69.20

97163 69.20 69.20

97164 47.19 47.19

97165 67.01 67.01

97166 67.01 67.01

97167 67.01 67.01

97168 44.34 44.34

97169 N.C. N.C.

97170 N.C. N.C.

97171 N.C. N.C.

97172 N.C. N.C.

97530 30.56 30.56 30.56

97533 22.86 22.86

97535 27.43 27.43

97537 23.73 23.73

97542 N.C. N.C.

97545 10.50 10.50

97546 N.C. N.C.

97597 59.82 22.26

97598 25.68 10.46

97602 N.C. N.C.

97605 32.38 19.95

97606 38.27 22.02

97607 37.79 23.62

97608 44.97 26.07

97610 96.00 12.20

97750 25.72 25.72 25.72

97755 27.68 27.68

97760 N.C. N.C.

97761 N.C. N.C.

97799 20.00 20.00

97802 30.03 30.03

97803 26.35 26.35

97804 13.55 13.55

97810 28.37 23.80

97811 21.11 19.68

97813 30.27 25.70

97814 23.86 21.59

Maryland Medical Assistance FS-95

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

98925 24.61 18.61 24.61

98926 35.56 27.87 35.56

98927 46.53 36.84 46.53

98928 56.63 46.09 56.63

98929 67.60 55.92 67.60

98940 22.00 17.44 22.00

98941 31.51 26.66 31.51

98942 41.04 36.19 41.04

98943 21.18 18.33 21.18

98960 N.C. N.C.

98961 N.C. N.C.

98962 N.C. N.C.

98966 N.C. N.C.

98967 N.C. N.C.

98968 N.C. N.C.

98969 N.C. N.C.

99000 N.C. N.C.

99001 N.C. N.C.

99002 15.00 15.00

99024 N.C. N.C.

99026 N.C. N.C.

99027 N.C. N.C.

99050 N.C. N.C.

99051 N.C. N.C.

99053 N.C. N.C.

99056 N.C. N.C.

99058 10.00 10.00

99060 N.C. N.C.

99070 9.99 9.99

99071 N.C. N.C.

99075 N.C. N.C.

99078 N.C. N.C.

99080 N.C. N.C.

99082 REPORT REPORT REPORT

99090 N.C. N.C.

99091 N.C. N.C.

99100 N.C. N.C.

99116 N.C. N.C.

99135 N.C. N.C.

99140 N.C. N.C.

99151 67.33 20.11

99152 44.90 10.50

99153 9.73 9.73

CODE NOTE NFAC FAC 26 TC

99155 78.98 78.98

99156 64.40 64.40

99157 48.81 48.81

99170 130.19 68.34

99172 4.50 4.50

99173 2.60 2.60

99174 7.00

99175 15.98 15.98 15.98

99177 7.00 7.00

99183 107.33 86.41 107.33

99184 197.50 197.50 197.50

99188 N.C. N.C.

99190 REPORT REPORT REPORT

99191 REPORT REPORT REPORT

99192 REPORT REPORT REPORT

99195 80.88 80.88 80.88

99199 REPORT REPORT REPORT

99201 45.37 27.04

99202 76.01 50.71

99203 109.40 77.13

99204 166.09 130.07

99205 208.77 169.52

99211 21.99 9.18

99212 44.57 25.51

99213 73.65 51.29

99214 108.50 78.43

99215 146.22 111.02

99217 N/A 73.40 73.40

99218 N/A 100.19

99219 N/A 136.14

99220 N/A 186.29

99221 N/A 101.86 101.86

99222 N/A 136.99 136.99

99223 N/A 203.07 203.07

99224 N/A 40.00

99225 N/A 73.14

99226 N/A 104.93

99231 N/A 39.26 39.26

99232 N/A 72.84 72.84

99233 N/A 104.26 104.26

99234 N/A 133.38 133.38

99235 N/A 169.33 169.33

99236 N/A 218.37 218.37

Maryland Medical Assistance FS-96

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

99238 N/A 73.40 73.40

99239 N/A 108.04 108.04

99241 48.00 32.49 48.00

99242 89.93 68.15 89.93

99243 123.01 95.31 123.01

99244 183.50 153.20 183.50

99245 223.47 189.46 223.47

99251 N/A 48.63 48.63

99252 N/A 74.42 74.42

99253 N/A 114.61 114.61

99254 N/A 166.44 166.44

99255 N/A 200.43 200.43

99281 N/A 21.18 21.18

99282 N/A 41.31 41.31

99283 N/A 61.72 61.72

99284 N/A 117.08 117.08

99285 N/A 172.43 172.43

99288 7.50 7.50 7.50

99291 276.18 222.85 276.18

99292 123.12 111.76 123.12

99304 91.48 91.48

99305 130.62 130.62

99306 166.94 166.94

99307 44.77 44.77

99308 69.59 69.59

99309 91.95 91.95

99310 136.55 136.55

99315 73.09 73.09 73.09

99316 106.27 106.27 106.27

99318 96.33 96.33

99324 55.28 55.28

99325 80.30 80.30

99326 139.24 139.24

99327 186.40 186.40

99328 218.08 218.08

99334 60.30 60.30

99335 94.98 94.98

99336 135.61 135.61

99337 193.51 193.51

99339 N.C. N.C.

99340 N.C. N.C.

99341 54.91 54.91 54.91

99342 79.56 79.56 79.56

CODE NOTE NFAC FAC 26 TC

99343 130.39 130.39 130.39

99344 182.92 182.92 182.92

99345 222.31 222.31 222.31

99347 55.30 55.30 55.30

99348 84.23 84.23 84.23

99349 128.90 128.90 128.90

99350 179.14 179.14 179.14

99354 130.73 121.92 130.73

99355 98.82 91.48 98.82

99356 N/A 92.29 92.29

99357 N/A 92.67 92.67

99358 N.C. N.C.

99359 N.C. N.C.

99360 N.C. N.C.

99366 N.C. N.C.

99367 N.C. N.C.

99368 N.C. N.C.

99374 N.C. N.C.

99375 N.C. N.C.

99377 N.C. N.C.

99378 N.C. N.C.

99379 N.C. N.C.

99380 N.C. N.C.

99381 111.73 76.54 111.73

99382 116.69 81.87 116.69

99383 121.22 86.76 121.22

99384 136.76 101.93 136.76

99385 132.49 97.66 132.49

99386 153.69 118.85 153.69

99387 166.54 127.47 166.54

99391 100.24 69.82 100.24

99392 106.97 76.54 106.97

99393 106.60 76.54 106.60

99394 116.82 86.75 116.82

99395 119.26 89.21 119.26

99396 127.04 96.73 127.04

99397 137.13 101.93 137.13

99401 N.C. N.C.

99402 N.C. N.C.

99403 N.C. N.C.

99404 N.C. N.C.

99406 14.58 12.39

99407 28.02 25.83

99408 N.C. N.C.

99409 N.C. N.C.

99411 N.C. N.C.

99412 N.C. N.C.

99415 10.33 10.33

99416 5.12 5.12

99429 REPORT REPORT REPORT

99441 N.C. N.C.

99442 N.C. N.C.

99443 N.C. N.C.

Maryland Medical Assistance FS-97

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

99444 N.C. N.C.

99446 N.C. N.C.

99447 N.C. N.C.

99448 N.C. N.C.

99449 N.C. N.C.

99450 N.C. N.C.

99455 N.C. N.C.

99456 N.C. N.C.

99460 N/A 95.98

99461 92.35 62.81

99462 41.61 41.61

99463 N/A 119.15

99464 74.77 74.77

99465 152.36 152.36

99466 238.28 238.28

99467 119.13 119.13

99468 N/A 939.57

99469 N/A 397.31

99471 N/A 878.71

99472 N/A 412.75

99475 N/A 575.11

99476 N/A 346.14

99477 356.25 356.25

99478 136.82 136.82

99479 124.18 124.18

99480 119.50 119.50

99485 76.54 76.54

99486 66.69 66.69

99487 N.C. N.C.

99489 N.C. N.C.

99490 N.C. N.C.

99495 165.88 110.16

99496 234.84 160.04

99497 N.C. N.C.

99498 N.C. N.C.

99499 REPORT REPORT REPORT

99500 N.C. N.C.

99501 N.C. N.C.

99502 N.C. N.C.

99503 N.C. N.C.

99504 N.C. N.C.

99505 N.C. N.C.

99506 N.C. N.C.

99507 N.C. N.C.

99509 N.C. N.C.

99510 N.C. N.C.

99511 N.C. N.C.

99512 N.C. N.C.

99600 N.C. N.C.

99601 N.C. N.C.

99602 N.C. N.C.

99605 N.C. N.C.

99606 N.C. N.C.

99607 N.C. N.C.

CODE NOTE NFAC FAC 26 TC

Maryland Medical Assistance FS-98

Professional Services Fee Schedule July 2018

Professional Services HCPCS Level II Fee Schedule

Effective July 1, 2018

Maryland Medical Assistance FS-99

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

A4261 INVOICE

A4266 INVOICE

A4641 INVOICE

A4642 INVOICE

A4648 INVOICE

A9155 6.14

A9500 121.69

A9502 121.05

A9503 23.67

A9504 INVOICE

A9505 34.20

A9507 INVOICE

A9508 576.19

A9510 218.11

A9512 INVOICE

A9516 103.47

A9517 31.73

A9521 567.67

A9524 59.09

A9526 109.86

A9527 20.41

A9528 50.57

A9529 INVOICE

A9530 INVOICE

A9531 INVOICE

A9532 INVOICE

A9536 760.00

A9537 59.54

A9538 24.86

A9539 16.25

A9540 244.63

A9541 32.14

A9542 INVOICE

A9543 INVOICE

A9546 235.83

A9547 291.61

A9548 272.21

A9549 1079.00

A9550 INVOICE

A9551 126.63

A9552 228.00

A9553 257.18

A9554 640.40

A9555 250.00

A9556 5.72

A9557 424.18

A9558 38.95

A9559 88.59

A9560 114.00

A9561 32.83

A9562 222.76

A9563 95.91

A9564 259.31

A9566 1045.80

A9567 81.23

A9568 1235.00

A9569 1482.64

A9572 3030.07

A9575 0.22

A9576 1.73

CODE NOTE NFAC FAC 26 TC

A9577 2.08

A9578 1.99

A9579 1.99

A9581 13.94

A9583 17.93

A9585 0.38

A9600 882.79

A9604 6484.39

A9606 INVOICE

A9699 INVOICE

G0296 30.13 25.45

G0297 220.27 220.27 46.32 173.94

G0420 86.58 86.58

G0421 20.50 20.50

G0452 19.47 19.47

G0453 26.20 26.20

G0455 112.28 58.19

J0120 15.10

J0129 49.59

J0130 1215.20

J0131 INVOICE

J0132 1.23

J0133 0.07

J0135 861.45

J0153 0.61

J0171 0.81

J0178 974.59

J0180 171.07

J0190 3.00

J0200 16.99

J0202 1778.60

J0205 41.98

J0207 959.81

J0210 42.40

J0215 30.63

J0220 206.64

J0221 159.73

J0256 4.94

J0257 4.57

J0270 0.63

J0275 24.35

J0278 1.63

J0280 9.22

J0282 0.26

J0285 32.78

J0287 13.86

J0288 14.00

J0289 21.52

J0290 1.11

J0295 2.97

J0300 6.33

J0330 0.19

J0348 0.54

J0350 2268.46

J0360 3.26

J0364 4.24

J0365 2.65

J0380 1.07

J0390 17.27

J0395 160.00

Maryland Medical Assistance FS-100

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

J0400 0.74

J0401 4.89

J0456 3.37

J0461 0.05

J0470 52.69

J0475 164.62

J0476 70.34

J0480 3440.37

J0485 3.94

J0490 42.81

J0500 74.94

J0515 20.22

J0520 4.49

J0558 9.34

J0561 11.92

J0570 1261.31

J0571 1.83

J0572 7.48

J0573 7.51

J0574 15.52

J0583 1.23

J0585 6.03

J0586 8.26

J0587 11.98

J0588 5.08

J0592 3.45

J0594 34.73

J0595 2.55

J0596 27.99

J0597 48.97

J0598 P 57.21

J0600 5594.42

J0610 2.98

J0620 10.03

J0630 2287.94

J0636 0.66

J0637 12.46

J0638 106.12

J0640 3.23

J0641 0.53

J0670 2.66

J0690 0.86

J0692 2.89

J0694 5.85

J0696 0.66

J0697 2.70

J0698 0.46

J0702 8.18

J0706 0.60

J0710 1.48

J0712 2.63

J0713 2.39

J0715 5.24

J0716 INVOICE

J0717 7.47

J0720 39.43

J0725 20.53

J0735 12.15

J0740 477.55

J0743 5.62

CODE NOTE NFAC FAC 26 TC

J0744 1.29

J0745 1.55

J0770 14.38

J0775 41.83

J0780 9.77

J0795 8.61

J0800 3771.36

J0833 73.19

J0834 43.06

J0840 2870.72

J0850 1128.71

J0875 14.40

J0878 0.62

J0881 3.95

J0885 12.94

J0887 1.63

J0888 1.63

J0890 9.07

J0894 17.70

J0895 8.04

J0897 17.33

J0945 0.80

J1000 19.54

J1020 5.59

J1030 6.36

J1040 12.26

J1050 0.50

J1071 0.03

J1094 0.23

J1100 0.12

J1110 105.62

J1120 21.25

J1160 8.40

J1162 3267.03

J1165 0.60

J1170 2.05

J1180 8.05

J1190 185.89

J1200 0.61

J1205 60.94

J1212 554.16

J1230 19.25

J1240 7.44

J1245 0.80

J1250 5.60

J1260 6.17

J1265 0.64

J1267 0.71

J1270 0.43

J1290 441.29

J1300 226.63

J1320 2.24

J1324 INVOICE

J1325 15.57

J1327 19.00

J1330 4.28

J1335 52.34

J1364 64.90

J1380 10.00

J1410 304.61

Maryland Medical Assistance FS-101

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

J1430 443.68

J1435 0.24

J1436 71.41

J1438 330.81

J1439 1.06

J1442 1.01

J1447 0.63

J1450 4.85

J1451 7.65

J1452 212.00

J1453 2.03

J1455 10.38

J1457 2.03

J1458 380.50

J1459 38.51

J1460 31.76

J1555 P 13.79

J1556 38.31

J1557 41.08

J1559 9.81

J1560 317.64

J1561 38.94

J1562 7.19

J1566 34.28

J1568 36.62

J1569 39.78

J1570 68.49

J1571 61.12

J1572 29.84

J1573 50.63

J1575 13.14

J1580 1.55

J1595 67.64

J1599 INVOICE

J1600 12.53

J1602 24.74

J1610 205.55

J1620 180.30

J1626 0.36

J1627 4.34

J1630 1.21

J1631 18.14

J1640 24.00

J1642 0.19

J1644 0.20

J1645 15.27

J1650 0.80

J1652 2.09

J1655 2.72

J1670 557.45

J1675 INVOICE

J1700 INVOICE

J1710 INVOICE

J1720 11.28

J1730 111.85

J1740 82.87

J1741 INVOICE

J1742 169.14

J1743 542.86

J1745 87.15

CODE NOTE NFAC FAC 26 TC

J1750 13.04

J1756 0.26

J1786 41.69

J1790 2.14

J1800 1.62

J1810 5.58

J1815 0.85

J1817 9.97

J1826 INVOICE

J1830 119.30

J1835 42.28

J1840 7.69

J1850 1.15

J1885 0.56

J1890 8.64

J1930 55.98

J1931 30.61

J1940 1.05

J1942 2.46

J1945 234.37

J1950 1087.91

J1953 0.12

J1955 22.08

J1956 1.18

J1960 3.23

J1980 27.62

J1990 21.05

J2001 0.02

J2010 12.58

J2020 13.91

J2060 0.74

J2150 2.05

J2170 INVOICE

J2175 5.10

J2180 3.79

J2185 1.33

J2210 16.11

J2212 INVOICE

J2248 0.94

J2250 0.11

J2260 1.94

J2265 INVOICE

J2270 1.42

J2274 12.40

J2278 7.42

J2280 8.31

J2300 2.70

J2310 28.83

J2315 3.26

J2320 3.75

J2323 19.42

J2325 38.37

J2350 P 57.08

J2353 183.64

J2354 0.96

J2355 467.22

J2357 34.93

J2358 2.92

J2360 6.91

J2370 0.76

Maryland Medical Assistance FS-102

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

J2400 23.21

J2405 0.09

J2407 23.36

J2410 2.85

J2425 19.20

J2426 10.02

J2430 8.42

J2440 0.76

J2460 0.94

J2469 20.90

J2501 1.10

J2503 729.47

J2504 352.27

J2505 4320.73

J2507 2006.66

J2510 29.30

J2513 12.72

J2515 52.40

J2540 1.05

J2543 2.96

J2545 115.20

J2550 2.17

J2560 35.86

J2562 314.44

J2590 0.59

J2597 12.75

J2650 0.17

J2670 3.44

J2675 1.46

J2680 18.71

J2690 72.65

J2700 1.70

J2704 0.12

J2710 0.09

J2720 0.91

J2724 15.13

J2725 15.75

J2730 91.90

J2760 159.00

J2765 0.91

J2770 428.62

J2778 378.35

J2780 6.77

J2783 263.06

J2785 55.41

J2788 24.71

J2790 79.07

J2791 4.81

J2792 23.80

J2793 INVOICE

J2794 8.63

J2795 0.07

J2796 66.86

J2800 37.24

J2805 105.54

J2810 0.30

J2820 37.70

J2850 34.78

J2910 24.50

J2916 2.13

CODE NOTE NFAC FAC 26 TC

J2920 4.34

J2930 6.09

J2940 42.30

J2941 51.96

J2950 0.38

J2993 2301.91

J2995 79.50

J2997 83.99

J3000 15.37

J3010 0.50

J3030 46.68

J3060 40.37

J3070 71.47

J3090 1.33

J3095 5.12

J3101 111.70

J3105 3.42

J3110 7.55

J3121 0.04

J3230 28.04

J3240 1579.69

J3243 2.99

J3246 7.39

J3250 29.98

J3260 2.54

J3262 4.37

J3265 2.19

J3280 INVOICE

J3285 61.24

J3300 3.88

J3301 1.88

J3302 0.28

J3303 3.61

J3305 149.71

J3310 6.20

J3315 391.11

J3320 30.08

J3355 60.01

J3357 187.26

J3358 12.85

J3360 9.16

J3364 9.16

J3365 457.73

J3370 2.75

J3380 18.59

J3385 342.35

J3396 10.76

J3400 11.26

J3410 8.51

J3411 3.03

J3415 10.32

J3420 2.09

J3430 4.15

J3465 2.70

J3470 14.19

J3471 0.39

J3472 137.80

J3473 0.36

J3475 0.55

J3480 0.12

Maryland Medical Assistance FS-103

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

J3485 1.52

J3486 22.18

J3489 14.98

J3490 P INVOICE

J3590 INVOICE

J7030 2.21

J7040 1.10

J7042 0.89

J7050 0.55

J7060 2.07

J7070 3.90

J7100 19.92

J7110 12.72

J7120 2.39

J7131 INVOICE

J7178 INVOICE

J7180 8.21

J7182 1.29

J7183 1.04

J7185 1.25

J7186 0.98

J7187 1.09

J7189 2.00

J7190 1.02

J7191 1.72

J7192 1.24

J7193 1.14

J7194 1.39

J7195 1.50

J7196 0.00

J7197 3.75

J7198 1.94

J7200 1.27

J7201 2.99

J7205 2.02

J7296 826.72

J7297 637.50

J7298 826.72

J7300 739.00

J7301 650.32

J7303 INVOICE

J7304 INVOICE

J7306 INVOICE

J7307 830.94

J7308 367.81

J7309 INVOICE

J7310 16960.00

J7311 20114.35

J7312 200.74

J7313 490.80

J7315 INVOICE

J7316 1046.75

J7320 7.42

J7321 87.64

J7323 155.23

J7324 149.48

J7325 12.27

J7326 510.57

J7327 856.79

J7330 25109.57

CODE NOTE NFAC FAC 26 TC

J7336 3.15

J7500 0.27

J7501 217.30

J7502 2.58

J7503 1.24

J7504 1817.04

J7505 1133.50

J7507 0.61

J7508 0.43

J7509 0.34

J7510 0.08

J7511 710.35

J7512 0.01

J7513 351.10

J7515 0.78

J7516 41.96

J7517 0.93

J7518 2.67

J7520 7.74

J7525 188.32

J7527 8.14

J7604 INVOICE

J7605 9.13

J7606 10.76

J7608 5.08

J7611 0.14

J7612 0.21

J7613 0.05

J7614 0.05

J7626 3.24

J7631 0.76

J7632 INVOICE

J7635 0.12

J7636 INVOICE

J7637 0.10

J7638 0.12

J7639 45.47

J7642 1.19

J7643 1.19

J7644 0.22

J7665 0.67

J7669 0.25

J7674 0.54

J7676 INVOICE

J7682 38.38

J7686 557.08

J8498 INVOICE

J8499 7.80

J8501 7.66

J8510 24.83

J8515 1.50

J8520 2.25

J8521 6.68

J8530 3.28

J8540 0.08

J8560 74.18

J8562 63.42

J8597 INVOICE

J8600 11.72

J8610 0.47

Maryland Medical Assistance FS-104

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

J8655 458.47

J8700 1.46

J8705 103.63

J9000 2.98

J9015 844.43

J9017 71.34

J9019 402.74

J9020 64.56

J9022 P 75.79

J9023 P 79.37

J9025 1.66

J9027 149.96

J9031 131.25

J9032 35.21

J9033 29.19

J9034 23.77

J9035 75.18

J9039 103.43

J9040 37.18

J9041 46.87

J9042 139.39

J9043 159.10

J9045 3.48

J9047 33.16

J9050 3863.47

J9055 57.62

J9060 2.08

J9065 20.66

J9070 42.06

J9098 641.67

J9100 0.82

J9120 1404.01

J9130 3.88

J9145 49.15

J9150 37.86

J9151 56.32

J9155 3.64

J9160 1494.82

J9165 12.89

J9171 1.89

J9175 4.07

J9176 6.26

J9178 1.43

J9179 109.16

J9181 0.50

J9185 104.89

J9190 1.62

J9200 72.67

J9201 5.82

J9202 327.12

J9205 P 41.13

J9206 3.39

J9207 74.10

J9208 26.85

J9209 2.15

J9211 29.76

J9212 4.80

J9213 40.53

J9214 26.86

J9215 8.17

CODE NOTE NFAC FAC 26 TC

J9216 430.93

J9217 209.71

J9218 17.90

J9219 4819.82

J9225 3138.04

J9226 P 26205.50

J9228 142.65

J9230 265.89

J9245 1369.46

J9250 0.24

J9260 2.38

J9261 151.66

J9263 0.19

J9264 10.32

J9266 13907.58

J9267 0.12

J9268 1887.77

J9270 78.99

J9271 46.50

J9280 103.17

J9285 P 49.95

J9293 36.75

J9295 5.29

J9299 26.06

J9301 56.20

J9302 51.87

J9303 105.60

J9305 62.78

J9306 10.65

J9307 229.72

J9308 55.93

J9310 848.41

J9315 306.79

J9320 322.73

J9328 8.24

J9330 66.67

J9340 113.53

J9351 1.25

J9352 289.17

J9354 29.22

J9355 92.09

J9357 1148.73

J9360 3.48

J9370 4.25

J9371 2506.49

J9390 9.29

J9395 95.77

J9400 8.15

J9600 2934.28

J9999 INVOICE

Q0138 0.88

Q0162 0.03

Q0163 0.27

Q0164 0.04

Q0166 0.41

Q0167 2.46

Q0169 0.02

Q0173 0.70

Q0175 0.51

Q0177 0.05

Maryland Medical Assistance FS-105

Professional Services Fee Schedule July 2018

CODE NOTE NFAC FAC 26 TC

Q0180 94.76

Q2009 0.45

Q2017 324.55

Q2034 INVOICE

Q2035 16.28

Q2037 16.28

Q2040 P INVOICE

Q2041 P INVOICE

Q2043 P 37763.36

Q2050 374.93

Q3014 23.72

Q3027 50.11

Q4074 123.93

Q4101 30.90

Q4104 38.89

Q4105 30.36

Q4106 33.23

Q4107 88.33

Q4108 40.70

Q4110 50.72

Q4111 6.88

Q4112 223.47

Q4113 223.47

Q4115 9.98

Q4116 32.20

Q4117 12.24

Q4123 20.06

Q4131 169.40

Q4172 119.12

Q5101 0.83

Q5102 78.72

Q9950 22.33

Q9953 62.05

Q9954 10.44

Q9956 34.55

Q9957 51.82

Q9958 0.08

Q9960 0.23

Q9961 0.20

Q9963 0.20

Q9965 0.85

Q9966 0.18

Q9967 0.12

Maryland Medical Assistance FS-106

Professional Services Fee Schedule July 2018