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Department of Health and Mental Hygiene Physicians’ Services Fee schedule 2016 Maryland Medical Assistance

Physicians’ Services Fee schedule 2015 · Physicians’ Services Fee Schedule - 2016. Introduction This Fee Schedule includes the current CPT codes and their maximum reimbursement

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Page 1: Physicians’ Services Fee schedule 2015 · Physicians’ Services Fee Schedule - 2016. Introduction This Fee Schedule includes the current CPT codes and their maximum reimbursement

Department of Health and Mental Hygiene

Physicians’ Services Fee schedule 2016

Maryland Medical Assistance

Page 2: Physicians’ Services Fee schedule 2015 · Physicians’ Services Fee Schedule - 2016. Introduction This Fee Schedule includes the current CPT codes and their maximum reimbursement

Physicians’ Services Fee Schedule - 2016 2016 Overview

Physicians’ Services Fee Schedule - 2016

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-6

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 any

HCPCS Level-II codes (beginning with Alpha characters A through

W) outside of the digital mammography codes (G0202, G0204,

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

There is no separate fee schedule for J-codes. All providers must

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bill J-codes 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:

http://mmcp.dhmh.maryland.gov.

This fee schedule does not contain any CPT Category II

(Performance Measurement) or CPT Category III (Emerging

Technology & Procedures). 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.

26 Modifier 26. The Modifier -26 Fee is the

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Physicians’ Services Fee Schedule - 2016 2016

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: http://mmcp.dhmh.maryland.gov/docs/ phys_forms.pdf

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.)

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Physicians’ Services Fee Schedule – 2016 2016

priced. Documentation may include (but is not limited to) medical notes, surgery notes, or invoices from a manufacturer or wholesaler.

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

N/C Rates with N/C are considered non-covered services by the Program

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.

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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 1.5707 1.5700 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

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CODE NOTE NFAC FAC 26 TC

00702 1.1486 1.1500 00730 1.1486 1.1500 00740 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 00810 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 00906 1.1486 1.1500 00908 1.1486 1.1500 00910 1.1486 1.1500

CODE NOTE NFAC FAC 26 TC

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 01180 1.1486 1.1500 01190 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 01260 1.1486 1.1500

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CODE NOTE NFAC FAC 26 TC

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 01654 1.1486 1.1500

CODE NOTE NFAC FAC 26 TC

01656 1.1486 1.1500 01670 1.1486 1.1500 01680 1.1486 1.1500 01682 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

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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 50.08 10022 108.10 47.94 10030 649.73 129.95 10035 471.14 74.96 10036 410.56 37.77 10040 66.63 59.58 10060 74.29 65.65 10061 130.61 116.66 10080 123.68 68.48 10081 188.25 116.62 10120 99.11 65.00 10121 188.68 133.17 10140 104.14 85.50 10160 87.79 69.00 10180 165.73 127.58 11000 37.05 23.50 11001 15.93 11.90 11004 408.91 408.91 11005 541.09 541.09 11006 512.73 512.73 11008 198.52 198.52 11010 339.78 204.58 11011 385.07 216.99 11012 539.08 319.19 11042 54.13 34.90

CODE NOTE NFAC FAC 26 TC

11043 187.00 128.88 11044 252.62 223.59 11045 25.87 14.88 11046 44.69 31.39 11047 73.49 54.69 11055 32.37 16.96 11056 39.83 23.79 11057 48.25 31.24 11100 67.31 33.51 11101 22.56 17.04 11200 55.52 47.47 11201 13.18 11.94 11300 46.22 20.60 11301 61.28 34.98 11302 72.91 43.05 11303 86.60 50.80 11305 47.47 26.82 11306 64.46 39.99 11307 74.69 46.30 11308 88.92 56.96 11310 56.53 29.88 11311 69.93 43.36 11312 81.30 49.93 11313 105.42 67.24 11400 84.52 52.59 11401 100.97 69.02 11402 112.14 75.86 11403 128.57 96.31 11404 146.08 106.70 11406 193.53 157.20 11420 84.29 57.31 11421 107.46 76.44 11422 120.13 91.61 11423 139.97 106.48 11424 160.36 123.14 11426 227.18 185.95 11440 93.88 69.38 11441 115.75 89.71 11442 129.93 99.54 11443 155.97 122.80 11444 195.84 156.77 11446 261.53 219.97 11450 243.83 160.12

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CODE NOTE NFAC FAC 26 TC

11451 329.22 212.61 11462 239.49 154.28 11463 335.42 215.41 11470 261.21 182.22 11471 346.45 231.08 11600 122.33 76.30 11601 144.97 97.94 11602 157.82 106.35 11603 179.29 125.93 11604 198.10 138.08 11606 275.94 204.25 11620 122.99 76.92 11621 146.15 99.16 11622 164.71 113.85 11623 192.53 139.72 11624 217.91 159.95 11626 279.01 204.40 11640 128.57 82.43 11641 160.41 108.26 11642 185.37 127.13 11643 214.22 158.07 11644 270.80 198.09 11646 359.25 280.79 11719 14.02 6.85 11720 20.93 12.49 11721 30.97 21.42 11730 68.04 43.75 11732 31.83 22.31 11740 30.38 22.95 11750 141.90 124.83 11752 201.22 181.86 11755 90.02 61.42 11760 135.28 97.47 11762 182.03 148.03 11765 86.42 48.13 11770 185.40 124.61 11771 359.37 284.94 11772 454.04 377.76 11900 36.76 21.22 11901 45.29 32.90 11920 142.37 82.52 11921 161.06 97.47 11922 46.62 22.11

CODE NOTE NFAC FAC 26 TC

11950 54.80 34.96 11951 71.26 47.37 11952 102.40 70.77 11954 120.93 80.93 11960 622.67 622.67 11970 420.29 420.29 11971 348.61 213.70 11976 105.58 70.23 11980 75.47 57.79 11981 97.50 61.21 11982 112.47 74.64 11983 168.46 135.27 12001 101.94 58.11 12002 113.25 74.50 12004 132.79 90.51 12005 165.27 117.52 12006 205.54 145.50 12007 231.38 170.90 12011 113.41 69.49 12013 124.53 78.39 12014 146.09 97.27 12015 183.37 119.36 12016 216.91 156.13 12017 181.27 181.27 12018 215.12 215.12 12020 193.50 133.96 12021 112.24 97.66 12031 150.64 103.53 12032 201.14 132.25 12034 196.18 136.70 12035 263.19 166.44 12036 291.15 195.33 12037 327.59 227.12 12041 160.13 112.19 12042 188.82 131.82 12044 214.31 144.40 12045 265.96 173.54 12046 314.47 204.06 12047 336.44 226.36 12051 178.12 122.56 12052 194.72 139.52 12053 213.19 144.80 12054 228.70 155.68

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CODE NOTE NFAC FAC 26 TC

12055 279.21 193.41 12056 359.45 240.36 12057 376.50 274.39 13100 220.42 163.04 13101 264.29 196.95 13102 74.88 52.86 13120 228.55 169.63 13121 287.40 219.92 13122 86.34 60.29 13131 251.21 192.18 13132 375.43 318.40 13133 116.82 92.94 13151 284.47 223.08 13152 380.07 298.96 13153 130.39 102.17 13160 562.63 562.63 14000 436.16 372.35 14001 565.61 497.85 14020 485.82 425.00 14021 634.87 575.57 14040 516.35 456.45 14041 695.15 628.42 14060 535.35 481.17 14061 754.45 680.89 14301 729.06 615.04 14302 159.07 159.07 14350 532.31 532.31 15002 232.12 161.00 15003 51.49 31.83 15004 279.34 199.11 15005 85.92 64.28 15040 190.50 92.51 15050 365.86 312.48 15100 636.09 514.22 15101 147.50 82.69 15110 620.75 526.77 15111 88.96 77.19 15115 598.67 541.50 15116 117.36 104.96 15120 645.88 553.58 15121 202.65 128.22 15130 496.43 404.94 15131 71.58 62.28

CODE NOTE NFAC FAC 26 TC

15135 618.35 553.55 15136 68.49 62.90 15150 514.17 463.01 15151 93.68 83.44 15152 115.15 104.29 15155 529.00 496.47 15156 123.46 115.40 15157 137.31 125.84 15200 548.54 455.40 15201 110.64 56.37 15220 533.63 437.58 15221 102.50 51.96 15240 609.04 550.82 15241 132.10 81.55 15260 648.18 592.57 15261 151.77 103.39 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 254.20 182.67 15278 70.03 46.28 15570 629.72 500.12 15572 590.99 495.49 15574 636.34 537.13 15576 565.89 472.24 15600 258.73 148.64 15610 224.56 174.44 15620 325.02 224.56 15630 322.22 243.31 15650 347.18 265.73 15731 766.03 692.03 15732 1075.29 929.59 15734 1108.45 959.92 15736 1000.10 832.28 15738 1059.49 906.92 15740 658.15 591.74 15750 645.24 645.24 15756 1691.95 1691.95 15757 1681.72 1681.72 15758 1680.27 1680.27

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CODE NOTE NFAC FAC 26 TC

15760 585.05 497.06 15770 450.65 450.65 15775 N.C. N.C. 15776 N.C. N.C. 15777 182.07 182.07 15780 P 585.53 468.72 15781 P 363.62 307.66 15782 P 410.79 301.31 15783 N.C. N.C. 15786 P 165.71 96.06 15787 P 39.45 13.40 15788 P 295.87 168.88 15789 P 398.63 297.66 15792 P 289.31 192.13 15793 P 314.47 248.12 15819 P 513.41 513.41 15820 P 375.36 335.91 15821 P 401.06 355.78 15822 P 298.88 260.41 15823 P 459.90 419.01 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 820.47 820.47 15832 P 633.38 633.38 15833 P 589.78 589.78 15834 P 591.50 591.50 15835 P 610.19 610.19 15836 P 513.33 513.33 15837 P 538.25 480.82 15838 P 404.36 404.36 15839 P 575.30 502.01 15840 713.38 713.38 15841 1181.31 1181.31 15842 1875.78 1875.78 15845 660.73 660.73 15847 P REPORT REPORT REPORT 15850 N.C. N.C. 15851 70.90 32.45 15852 33.93 33.93 15860 80.43 80.43

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 410.27 410.27 15922 529.09 529.09 15931 468.69 468.69 15933 579.34 579.34 15934 646.75 646.75 15935 766.67 766.67 15936 631.40 631.40 15937 739.34 739.34 15940 485.43 485.43 15941 642.35 642.35 15944 624.97 624.97 15945 691.25 691.25 15946 1143.60 1143.60 15950 402.87 402.87 15951 574.38 574.38 15952 596.71 596.71 15953 666.18 666.18 15956 809.02 809.02 15958 827.01 827.01 15999 REPORT REPORT REPORT 16000 49.74 33.00 16020 60.11 40.57 16025 105.20 81.64 16030 126.81 93.94 16035 153.49 153.49 16036 61.05 61.05 17000 51.78 36.87 17003 5.47 3.60 17004 123.69 96.08 17106 273.93 232.37 17107 423.96 347.52 17108 537.14 448.67 17110 70.35 43.28 17111 83.18 55.60 17250 53.85 25.84 17260 66.80 46.64 17261 92.06 61.75 17262 111.71 78.81 17263 123.02 86.88

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CODE NOTE NFAC FAC 26 TC

17264 132.90 92.82 17266 150.51 107.10 17270 96.31 66.49 17271 105.29 74.92 17272 120.65 86.88 17273 134.26 97.63 17274 159.66 119.75 17276 187.86 144.50 17280 90.27 60.83 17281 114.17 84.49 17282 132.19 97.65 17283 159.89 122.48 17284 186.79 145.81 17286 247.72 198.42 17311 494.51 261.89 17312 299.13 139.48 17313 451.81 235.26 17314 277.05 128.99 17315 58.10 36.82 17340 32.30 32.61 17360 87.45 68.19 17380 N.C. N.C. 17999 REPORT REPORT REPORT 19000 84.53 33.06 19001 19.79 16.37 19020 310.72 198.46 19030 128.18 58.40 19081 560.46 151.32 19082 453.77 72.60 19083 556.79 139.20 19084 447.68 67.15 19085 844.09 168.82 19086 673.43 74.08 19100 102.07 49.05 19101 231.90 151.59 19105 1502.50 135.23 19110 313.03 221.56 19112 301.08 200.61 19120 319.41 271.82 19125 342.99 301.32 19126 113.85 113.85 19260 844.48 844.48 19271 1166.27 1166.27

CODE NOTE NFAC FAC 26 TC

19272 1284.07 1284.07 19281 200.15 84.06 19282 139.37 39.02 19283 227.75 84.27 19284 167.56 40.21 19285 388.18 69.87 19286 326.30 35.89 19287 721.07 115.37 19288 574.44 51.70 19296 3383.91 146.52 19297 66.06 66.06 19298 1163.06 237.73 19300 375.49 267.24 19301 390.29 390.29 19302 595.44 595.44 19303 601.64 601.64 19304 374.11 374.11 19305 737.52 737.52 19306 766.93 766.93 19307 771.12 771.12 19316 P 556.15 556.15 19318 P 824.01 824.01 19324 P 341.37 341.37 19325 P 459.79 459.79 19328 342.25 342.25 19330 437.64 437.64 19340 286.37 286.37 19342 645.62 645.62 19350 641.92 487.15 19355 517.15 388.74 19357 1081.68 1081.68 19361 1092.86 1092.86 19364 1988.26 1988.26 19366 989.62 989.62 19367 1300.55 1300.55 19368 1604.39 1604.39 19369 1472.84 1472.84 19370 478.69 478.69 19371 552.92 552.92 19380 538.67 538.67 19396 145.96 100.22 19499 REPORT REPORT REPORT 20005 284.10 225.06

Maryland Medical Assistance FS-13

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

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 651.76 116.01 20240 219.35 219.35 20245 598.76 598.76 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 52.30 38.87 20604 77.19 48.52 20605 56.16 40.05 20606 84.75 54.90 20610 72.33 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 704.39 704.39 20665 115.09 97.04 20670 370.27 143.07 20680 552.55 380.32 20690 467.45 467.45

CODE NOTE NFAC FAC 26 TC

20692 859.93 859.93 20693 440.42 440.42 20694 401.45 322.16 20696 1047.65 1047.65 20697 1261.48 1261.48 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 2181.95 2181.95 20827 1927.89 1927.89 20838 2227.10 2227.10 20900 405.93 244.65 20902 345.32 345.32 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 20950 232.24 88.14 20955 2418.90 2418.90 20956 2577.68 2577.68 20957 2418.15 2418.15 20962 2544.33 2544.33 20969 2687.89 2687.89 20970 2700.06 2700.06 20972 2398.41 2398.41 20973 2608.16 2608.16 20974 59.22 46.20 20975 172.21 172.21 20979 50.93 35.26 20982 3591.49 388.24 20983 7696.18 430.99 20985 143.57 143.57 20999 REPORT REPORT REPORT 21010 685.11 685.11

Maryland Medical Assistance FS-14

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

21011 319.30 248.73 21012 340.02 340.02 21013 494.51 399.56 21014 524.39 346.10 21015 405.29 405.29 21016 1052.94 694.84 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 REPORT REPORT REPORT 21089 REPORT REPORT REPORT 21100 662.77 373.80 21110 685.14 593.13 21116 140.94 41.06 21120 581.14 467.18 21121 710.84 609.83 21122 680.26 680.26

CODE NOTE NFAC FAC 26 TC

21123 797.85 797.85 21125 2820.54 693.29 21127 3076.89 819.38 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 1649.59 1649.59 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 1829.04 782.65 21215 3070.53 817.07 21230 729.84 729.84 21235 674.98 528.17 21240 1059.62 1059.62 21242 969.05 969.05 21243 1584.29 1584.29

Maryland Medical Assistance FS-15

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

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 99.37 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 21366 1166.73 1166.73 21385 672.30 672.30

CODE NOTE NFAC FAC 26 TC

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 668.84 580.35 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 497.74 428.80 21451 664.42 577.71 21452 559.25 305.63 21453 766.19 697.16 21454 519.05 519.05 21461 1693.33 859.70 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 21495 624.85 624.85 21497 591.32 516.40 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 481.20 323.66 21554 743.25 743.25 21555 400.75 305.45 21556 383.93 383.93 21557 545.25 545.25

Maryland Medical Assistance FS-16

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

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 363.22 363.22 21725 503.24 503.24 21740 1024.35 1024.35 21742 REPORT REPORT REPORT 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 22206 2217.30 2217.30

CODE NOTE NFAC FAC 26 TC

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 22305 175.06 161.27 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 1903.10 479.39 22511 1886.42 449.35 22512 1054.99 217.64 22513 8090.28 547.71 22514 8061.69 511.92 22515 4894.45 228.08 22526 1851.73 334.24 22527 1436.33 151.82 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-17

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Physicians’ Services Fee Schedule – 2016 2016

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 22851 404.84 404.84 22852 652.62 652.62 22855 1054.73 1054.73 22856 1612.07 1612.07 22857 1646.93 1646.93 22858 735.58 735.58 22861 1943.36 1943.36 22862 1916.66 1916.66 22864 1809.21 1809.21 22865 1910.87 1910.87 22899 REPORT REPORT REPORT 22900 375.38 375.38 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

CODE NOTE NFAC FAC 26 TC

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 241.19 166.06 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 23195 711.89 711.89 23200 827.63 827.63 23210 867.23 867.23 23220 1024.03 1024.03 23330 208.03 140.17 23333 474.57 474.57

Maryland Medical Assistance FS-18

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

23334 1117.79 1117.79 23335 1331.95 1331.95 23350 149.79 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 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

CODE NOTE NFAC FAC 26 TC

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 769.25 769.25 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 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

Maryland Medical Assistance FS-19

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

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 931.09 931.09 24152 687.57 687.57 24155 802.55 802.55 24160 576.02 576.02 24164 470.37 470.37 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 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

CODE NOTE NFAC FAC 26 TC

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 624.41 624.41 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 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

Maryland Medical Assistance FS-20

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

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 311.24 311.24 25076 420.82 420.82 25077 712.79 712.79 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 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

CODE NOTE NFAC FAC 26 TC

25145 541.87 541.87 25150 551.32 551.32 25151 609.96 609.96 25170 849.22 849.22 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 501.89 501.89 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 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

Maryland Medical Assistance FS-21

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

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 579.81 579.81 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 258.74 232.48 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

CODE NOTE NFAC FAC 26 TC

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 1189.61 1189.61 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 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

Maryland Medical Assistance FS-22

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

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 569.14 333.52 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 546.95 546.95 26260 514.49 514.49 26262 430.43 430.43 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 988.06 988.06

CODE NOTE NFAC FAC 26 TC

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 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

Maryland Medical Assistance FS-23

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

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 2721.42 2721.42 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 26600 245.99 220.55 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

CODE NOTE NFAC FAC 26 TC

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 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

Maryland Medical Assistance FS-24

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

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 445.30 445.30 27049 933.26 933.26 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 1522.61 1522.61 27077 2547.69 2547.69 27078 961.05 961.05 27080 458.42 458.42 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

CODE NOTE NFAC FAC 26 TC

27096 168.60 63.93 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 1009.04 1009.04 27185 625.49 625.49 27187 957.08 957.08 27193 437.93 440.38 27194 686.82 686.82 27200 159.28 162.70 27202 608.45 608.45 27215 661.68 661.68 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

Maryland Medical Assistance FS-25

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

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 214.72 214.72 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 979.58 979.58 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 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

CODE NOTE NFAC FAC 26 TC

27326 463.50 463.50 27327 419.54 326.61 27328 394.92 394.92 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 1166.22 1166.22 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 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

Maryland Medical Assistance FS-26

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

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 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

CODE NOTE NFAC FAC 26 TC

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 359.45 335.04 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 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

Maryland Medical Assistance FS-27

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

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 525.81 525.81 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 1014.71 1014.71 27646 896.03 896.03 27647 789.94 789.94 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 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

CODE NOTE NFAC FAC 26 TC

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 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

Maryland Medical Assistance FS-28

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

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 457.02 369.09 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

CODE NOTE NFAC FAC 26 TC

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 314.18 255.81 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 28120 531.46 390.78 28122 605.87 498.81 28124 428.22 333.75 28126 345.19 251.26 28130 623.25 623.25 28140 580.15 454.72

Maryland Medical Assistance FS-29

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

28150 389.08 286.99 28153 358.28 257.71 28160 369.08 272.27 28171 602.76 602.76 28173 682.51 550.17 28175 499.17 386.81 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 416.08 318.38 28286 408.86 307.05 28288 518.35 415.92 28289 669.07 540.41 28290 519.77 397.94 28292 693.79 569.19 28293 933.46 685.07 28294 678.91 527.85 28296 682.59 538.09 28297 762.18 602.96 28298 648.43 507.14 28299 832.60 679.48 28300 651.60 651.60

CODE NOTE NFAC FAC 26 TC

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 413.63 299.63 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 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

Maryland Medical Assistance FS-30

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

28530 103.99 96.37 28531 337.10 185.00 28540 184.43 172.61 28545 217.08 204.47 28546 429.43 284.20 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 249.42 233.41 28606 373.63 373.63 28615 734.38 734.38 28630 135.52 104.57 28635 163.06 133.24 28636 271.20 195.07 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 810.73 810.73 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 432.72 279.62 28890 321.30 216.97 28899 REPORT REPORT REPORT 29000 234.18 160.91 29010 228.91 153.44 29015 219.40 154.22 29035 219.92 133.18

CODE NOTE NFAC FAC 26 TC

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 48.93 37.35 29240 54.95 42.06 29260 47.58 34.67 29280 45.71 32.75 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 88.87 68.57 29435 109.23 83.20 29440 48.72 32.94 29445 136.92 108.36 29450 143.22 121.11 29505 69.49 44.91 29515 65.18 46.86 29520 46.05 34.99 29530 48.31 35.45 29540 35.08 24.77 29550 28.42 17.00 29580 48.88 35.04 29581 90.63 33.03 29582 75.75 16.01 29583 46.86 11.76 29584 75.75 16.01 29700 59.39 32.94

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CODE NOTE NFAC FAC 26 TC

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 645.31 645.31 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 29861 678.52 678.52 29862 763.22 763.22 29863 752.68 752.68

CODE NOTE NFAC FAC 26 TC

29866 1007.55 1007.55 29867 1218.29 1218.29 29868 1635.54 1635.54 29870 389.07 389.07 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 653.16 653.16 29881 608.85 608.85 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 30000 159.76 83.57 30020 150.24 85.44 30100 93.25 50.61

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CODE NOTE NFAC FAC 26 TC

30110 151.12 92.33 30115 295.45 295.45 30117 553.12 238.34 30118 529.93 529.93 30120 348.75 311.82 30124 193.80 193.80 30125 431.09 431.09 30130 260.65 260.65 30140 294.14 294.14 30150 559.09 559.09 30160 554.39 554.39 30200 75.33 44.03 30210 98.66 68.30 30220 191.79 89.64 30300 161.27 88.25 30310 143.18 143.18 30320 323.81 323.81 30400 P 730.03 730.03 30410 P 882.54 882.54 30420 P 956.44 956.44 30430 P 655.23 655.23 30435 P 861.42 861.42 30450 P 1114.32 1114.32 30460 542.91 542.91 30462 1090.91 1090.91 30465 675.92 675.92 30520 402.10 402.10 30540 478.42 478.42 30545 676.12 676.12 30560 184.45 100.60 30580 429.80 348.83 30600 396.82 307.50 30620 426.86 426.86 30630 428.78 428.78 30801 155.82 94.05 30802 198.16 128.17 30901 72.57 44.25 30903 131.33 58.00 30905 164.62 75.30 30906 188.30 99.67 30915 394.92 394.92 30920 563.34 563.34 30930 83.77 83.77

CODE NOTE NFAC FAC 26 TC

30999 REPORT REPORT REPORT 31000 121.79 75.08 31002 140.59 140.59 31020 337.49 242.22 31030 490.96 359.92 31032 392.68 392.68 31040 520.47 520.47 31050 337.19 337.19 31051 442.77 442.77 31070 298.27 298.27 31075 538.30 538.30 31080 705.55 705.55 31081 854.23 854.23 31084 792.74 792.74 31085 854.91 854.91 31086 769.94 769.94 31087 757.99 757.99 31090 683.33 683.33 31200 381.08 381.08 31201 504.61 504.61 31205 597.39 597.39 31225 1233.14 1233.14 31230 1387.55 1387.55 31231 133.81 56.55 31233 187.20 102.55 31235 215.05 121.93 31237 232.12 135.98 31238 238.27 147.68 31239 461.33 461.33 31240 121.08 121.08 31254 199.12 199.12 31255 306.49 306.49 31256 150.62 150.62 31267 232.67 232.67 31276 370.56 370.56 31287 176.60 176.60 31288 204.68 204.68 31290 812.76 812.76 31291 858.30 858.30 31292 704.02 704.02 31293 766.01 766.01 31294 880.44 880.44 31295 1726.42 145.19

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CODE NOTE NFAC FAC 26 TC

31296 3235.05 173.08 31297 3205.67 142.01 31299 REPORT REPORT REPORT 31300 863.20 863.20 31320 457.11 457.11 31360 1321.11 1321.11 31365 1656.67 1656.67 31367 1462.14 1462.14 31368 1648.76 1648.76 31370 1386.89 1386.89 31375 1303.43 1303.43 31380 1291.19 1291.19 31382 1408.25 1408.25 31390 1859.83 1859.83 31395 1995.19 1995.19 31400 699.63 699.63 31420 574.49 574.49 31500 76.86 76.86 31502 25.95 25.95 31505 59.52 35.93 31510 149.22 89.34 31511 149.14 93.60 31512 148.38 96.22 31513 94.75 94.75 31515 149.11 80.86 31520 110.14 110.14 31525 177.02 114.18 31526 113.69 113.69 31527 137.34 137.34 31528 102.08 102.08 31529 116.79 116.79 31530 142.79 142.79 31531 154.44 154.44 31535 142.56 142.56 31536 159.61 159.61 31540 175.64 175.64 31541 195.46 195.46 31545 255.90 255.90 31546 388.59 388.59 31560 235.70 235.70 31561 257.45 257.45 31570 252.57 166.85 31571 181.37 181.37

CODE NOTE NFAC FAC 26 TC

31575 83.48 56.85 31576 159.61 91.17 31577 173.67 112.02 31578 200.22 124.48 31579 166.66 104.33 31580 837.70 837.70 31582 1337.59 1337.59 31584 1051.45 1051.45 31587 669.30 669.30 31588 781.83 781.83 31590 635.02 635.02 31595 537.23 537.23 31599 REPORT REPORT REPORT 31600 281.98 281.98 31601 183.11 183.11 31603 158.46 158.46 31605 133.10 133.10 31610 491.05 491.05 31611 370.34 370.34 31612 57.26 35.14 31613 307.58 307.58 31614 499.08 499.08 31615 130.52 89.72 31622 236.42 107.59 31623 259.89 108.45 31624 240.83 108.47 31625 256.76 126.61 31626 326.88 160.60 31627 912.41 78.10 31628 307.65 140.84 31629 497.26 150.07 31630 148.09 148.09 31631 165.16 165.16 31632 55.43 38.75 31633 65.50 47.63 31634 1529.18 169.43 31635 266.35 141.54 31636 161.72 161.72 31637 57.13 57.13 31638 179.81 179.81 31640 188.88 188.88 31641 184.77 184.77 31643 125.82 125.82

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CODE NOTE NFAC FAC 26 TC

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 82.86 82.86 31652 794.13 202.03 31653 843.50 222.94 31654 93.91 58.29 31660 191.19 191.19 31661 201.84 201.84 31717 266.59 82.27 31720 37.12 37.12 31725 67.30 67.30 31730 492.66 106.81 31750 928.13 928.13 31755 1185.80 1185.80 31760 968.09 968.09 31766 1289.01 1289.01 31770 942.49 942.49 31775 1010.75 1010.75 31780 831.22 831.22 31781 1002.72 1002.72 31785 764.79 764.79 31786 1060.04 1060.04 31800 490.33 490.33 31805 582.82 582.82 31820 295.82 227.34 31825 413.41 335.11 31830 299.33 237.40 31899 REPORT REPORT REPORT 32035 491.18 491.18 32036 532.96 532.96 32096 N.C. N.C. 32097 703.30 703.30 32098 660.94 660.94 32100 683.15 683.15 32110 1022.02 1022.02 32120 606.58 606.58 32124 645.14 645.14 32140 690.68 690.68 32141 993.29 993.29 32150 696.35 696.35

CODE NOTE NFAC FAC 26 TC

32151 711.92 711.92 32160 525.76 525.76 32200 777.63 777.63 32215 564.27 564.27 32220 1126.58 1126.58 32225 696.06 696.06 32310 645.81 645.81 32320 1121.92 1121.92 32400 110.23 65.80 32405 71.27 70.67 32440 1133.06 1133.06 32442 2006.46 2006.46 32445 2232.39 2232.39 32480 1068.13 1068.13 32482 1138.01 1138.01 32484 1025.68 1025.68 32486 1576.62 1576.62 32488 1607.66 1607.66 32491 1050.18 1050.18 32501 177.32 177.32 32503 1312.43 1312.43 32504 1496.04 1496.04 32505 811.10 811.10 32506 136.53 136.53 32507 136.53 136.53 32540 1123.11 1123.11 32550 635.49 162.30 32551 128.39 128.39 32552 132.24 116.90 32553 429.68 150.35 32554 491.10 75.38 32555 566.08 94.31 32556 516.75 103.40 32557 841.48 140.95 32560 232.41 79.93 32561 68.78 52.36 32562 61.14 46.87 32601 223.63 223.63 32604 349.58 349.58 32606 336.44 336.44 32607 269.13 269.13 32608 330.47 330.47 32609 228.81 228.81

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CODE NOTE NFAC FAC 26 TC

32650 490.37 490.37 32651 739.35 739.35 32652 1113.62 1113.62 32653 717.23 717.23 32654 784.06 784.06 32655 663.15 663.15 32656 587.70 587.70 32658 528.53 528.53 32659 537.32 537.32 32661 589.90 589.90 32662 661.95 661.95 32663 986.72 986.72 32664 615.62 615.62 32665 841.93 841.93 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 656.55 656.55 32810 638.64 638.64 32815 1768.84 1768.84 32820 963.97 963.97 32850 P 444.00 444.00 32851 P 1886.12 1886.12 32852 P 2108.01 2108.01 32853 P 2255.59 2255.59 32854 P 2442.13 2442.13 32855 P REPORT REPORT REPORT 32856 P REPORT REPORT REPORT 32900 960.50 960.50 32905 957.00 957.00 32906 1180.40 1180.40 32940 875.89 875.89 32960 100.20 68.63 32997 253.00 253.00 32998 2243.27 218.94 32999 REPORT REPORT REPORT

CODE NOTE NFAC FAC 26 TC

33010 86.57 86.57 33011 88.65 88.65 33015 378.12 378.12 33020 615.60 615.60 33025 571.42 571.42 33030 910.54 910.54 33031 1008.53 1008.53 33050 705.44 705.44 33120 1112.57 1112.57 33130 972.09 972.09 33140 1097.76 1097.76 33141 117.70 117.70 33202 555.60 555.60 33203 567.26 567.26 33206 338.81 338.81 33207 362.17 362.17 33208 387.41 387.41 33210 130.57 130.57 33211 133.37 133.37 33212 253.93 253.93 33213 288.74 288.74 33214 362.18 362.18 33215 231.07 231.07 33216 284.59 284.59 33217 283.40 283.40 33218 294.48 294.48 33220 295.56 295.56 33221 305.11 305.11 33222 264.18 264.18 33223 315.06 315.06 33224 372.11 372.11 33225 332.73 332.73 33226 359.42 359.42 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 186.17 186.17 33234 365.39 365.39 33235 476.26 476.26 33236 567.07 567.07 33237 621.36 621.36

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CODE NOTE NFAC FAC 26 TC

33238 678.66 678.66 33240 346.92 346.92 33241 174.72 174.72 33243 973.87 973.87 33244 644.55 644.55 33249 670.36 670.36 33250 1056.04 1056.04 33251 1153.27 1153.27 33254 970.41 970.41 33255 1167.14 1167.14 33256 1393.14 1393.14 33257 426.97 426.97 33258 482.20 482.20 33259 633.32 633.32 33261 1161.54 1161.54 33262 316.36 316.36 33263 328.80 328.80 33264 341.22 341.22 33265 970.41 970.41 33266 1326.30 1326.30 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 1551.00 1551.00 33305 2528.11 2528.11 33310 842.05 842.05 33315 1055.21 1055.21 33320 758.40 758.40 33321 866.44 866.44 33322 980.31 980.31 33330 998.54 998.54 33335 1344.08 1344.08 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

CODE NOTE NFAC FAC 26 TC

33369 853.35 853.35 33400 1593.14 1593.14 33401 1060.58 1060.58 33403 1129.83 1129.83 33404 1293.07 1293.07 33405 1670.00 1670.00 33406 2016.60 2016.60 33410 1773.81 1773.81 33411 2285.14 2285.14 33412 1811.77 1811.77 33413 2327.57 2327.57 33414 1527.09 1527.09 33415 1414.61 1414.61 33416 1431.34 1431.34 33417 1216.55 1216.55 33418 1494.19 1566.66 33419 492.90 492.90 33420 972.37 972.37 33422 1218.29 1218.29 33425 1808.28 1808.28 33426 1702.58 1702.58 33427 1803.20 1803.20 33430 1937.22 1937.22 33460 1592.06 1592.06 33463 2008.89 2008.89 33464 1658.68 1658.68 33465 1835.29 1835.29 33468 1359.49 1359.49 33470 835.34 835.34 33471 980.02 980.02 33474 1420.36 1420.36 33475 1641.16 1641.16 33476 1056.40 1056.40 33477 1130.98 1130.98 33478 1147.63 1147.63 33496 1208.90 1208.90 33500 1134.53 1134.53 33501 778.46 778.46 33502 926.87 926.87 33503 931.91 931.91 33504 1056.12 1056.12 33505 1431.37 1431.37 33506 1475.72 1475.72

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

33507 1260.91 1260.91 33508 11.72 11.72 33510 1425.44 1425.44 33511 1545.12 1545.12 33512 1720.05 1720.05 33513 1769.86 1769.86 33514 1852.32 1852.32 33516 1924.42 1924.42 33517 134.55 134.55 33518 287.40 287.40 33519 386.40 386.40 33521 471.77 471.77 33522 542.32 542.32 33523 622.62 622.62 33530 363.01 363.01 33533 1395.66 1395.66 33534 1603.04 1603.04 33535 1762.44 1762.44 33536 1883.19 1883.19 33542 1761.98 1761.98 33545 2092.77 2092.77 33548 2070.78 2070.78 33572 176.63 176.63 33600 1240.26 1240.26 33602 1183.64 1183.64 33606 1283.84 1283.84 33608 1322.42 1322.42 33610 1308.19 1308.19 33611 1398.75 1398.75 33612 1493.78 1493.78 33615 1410.65 1410.65 33617 1572.51 1572.51 33619 1965.98 1965.98 33620 1450.45 1450.45 33621 768.75 768.75 33622 3014.24 3014.24 33641 1128.18 1128.18 33645 1135.65 1135.65 33647 1216.97 1216.97 33660 1291.50 1291.50 33665 1363.12 1363.12 33670 1467.93 1467.93 33675 1499.09 1499.09

CODE NOTE NFAC FAC 26 TC

33676 1546.61 1546.61 33677 1607.55 1607.55 33681 1334.18 1334.18 33684 1347.53 1347.53 33688 1322.76 1322.76 33690 836.84 836.84 33692 1406.83 1406.83 33694 1390.99 1390.99 33697 1519.39 1519.39 33702 1120.37 1120.37 33710 1251.98 1251.98 33720 1123.65 1123.65 33722 1122.16 1122.16 33724 1105.52 1105.52 33726 1455.04 1455.04 33730 1437.43 1437.43 33732 1206.45 1206.45 33735 898.96 898.96 33736 1042.97 1042.97 33737 944.60 944.60 33750 872.79 872.79 33755 895.91 895.91 33762 926.18 926.18 33764 927.29 927.29 33766 985.26 985.26 33767 1032.96 1032.96 33768 298.95 298.95 33770 1526.15 1526.15 33771 1546.41 1546.41 33774 1318.39 1318.39 33775 1329.08 1329.08 33776 1388.47 1388.47 33777 1377.90 1377.90 33778 1706.47 1706.47 33779 1567.88 1567.88 33780 1671.97 1671.97 33781 1603.65 1603.65 33782 2331.99 2331.99 33783 2520.64 2520.64 33786 1655.80 1655.80 33788 1090.99 1090.99 33800 719.30 719.30 33802 772.39 772.39

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CODE NOTE NFAC FAC 26 TC

33803 831.57 831.57 33813 909.13 909.13 33814 1107.36 1107.36 33820 706.64 706.64 33822 734.75 734.75 33824 854.82 854.82 33840 879.77 879.77 33845 964.60 964.60 33851 923.08 923.08 33852 1052.67 1052.67 33853 1332.37 1332.37 33860 2181.12 2181.12 33863 2213.07 2213.07 33864 2277.74 2277.74 33870 1842.89 1842.89 33875 1425.60 1425.60 33877 2432.54 2432.54 33880 1296.52 1296.52 33881 1119.57 1119.57 33883 824.80 824.80 33884 297.11 297.11 33886 714.26 714.26 33889 592.93 592.93 33891 763.52 763.52 33910 1177.90 1177.90 33915 936.34 936.34 33916 1135.98 1135.98 33917 1059.36 1059.36 33920 1278.91 1278.91 33922 1000.18 1000.18 33924 210.45 210.45 33925 1368.83 1368.83 33926 1768.16 1768.16 33930 N.C. N.C. 33933 P REPORT REPORT REPORT 33935 P 2556.54 2556.54 33940 N.C. N.C. 33944 P REPORT REPORT REPORT 33945 P 3158.60 3158.60 33946 276.14 276.14 33947 300.41 300.41 33948 210.03 210.03 33949 205.00 205.00

CODE NOTE NFAC FAC 26 TC

33951 336.20 334.01 33952 327.15 324.34 33953 374.14 371.97 33954 364.15 361.02 33955 783.46 780.64 33956 739.44 736.33 33957 270.55 267.74 33958 264.62 262.42 33959 310.05 307.23 33962 296.00 292.89 33963 495.97 493.14 33964 501.16 498.95 33965 267.74 267.74 33966 294.06 373.81 33967 193.36 193.36 33968 24.90 24.90 33969 305.34 302.84 33970 262.28 262.28 33971 509.85 509.85 33973 385.70 385.70 33974 652.22 652.22 33975 794.35 794.35 33976 888.62 888.62 33977 882.40 882.40 33978 982.09 982.09 33979 1756.56 1756.56 33980 2571.62 2571.62 33981 REPORT REPORT REPORT 33982 REPORT REPORT REPORT 33983 REPORT REPORT REPORT 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 REPORT REPORT REPORT 33991 REPORT REPORT REPORT 33992 REPORT REPORT REPORT 33993 REPORT REPORT REPORT 33999 REPORT REPORT REPORT 34001 688.25 688.25 34051 708.54 708.54

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CODE NOTE NFAC FAC 26 TC

34101 452.72 452.72 34111 452.13 452.13 34151 1039.64 1039.64 34201 700.07 700.07 34203 721.44 721.44 34401 1039.80 1039.80 34421 544.65 544.65 34451 1123.64 1123.64 34471 750.67 750.67 34490 454.21 454.21 34501 703.79 703.79 34502 1132.80 1132.80 34510 809.41 809.41 34520 767.93 767.93 34530 719.12 719.12 34800 846.48 846.48 34802 921.86 921.86 34803 942.39 942.39 34804 919.54 919.54 34805 869.17 869.17 34806 74.65 74.65 34808 154.96 154.96 34812 258.71 258.71 34813 178.30 178.30 34820 368.64 368.64 34825 519.98 519.98 34826 151.93 151.93 34830 1357.30 1357.30 34831 1419.91 1419.91 34832 1469.69 1469.69 34833 460.17 460.17 34834 209.86 209.86 34839 REPORT REPORT REPORT 34841 REPORT REPORT REPORT 34842 REPORT REPORT REPORT 34843 REPORT REPORT REPORT 34844 REPORT REPORT REPORT 34845 REPORT REPORT REPORT 34846 REPORT REPORT REPORT 34847 REPORT REPORT REPORT 34848 REPORT REPORT REPORT 34900 675.72 675.72 35001 849.95 849.95

CODE NOTE NFAC FAC 26 TC

35002 889.94 889.94 35005 784.69 784.69 35011 743.58 743.58 35013 920.26 920.26 35021 895.26 895.26 35022 1029.48 1029.48 35045 719.50 719.50 35081 1271.56 1271.56 35082 1611.91 1611.91 35091 1373.25 1373.25 35092 1920.11 1920.11 35102 1381.24 1381.24 35103 1666.07 1666.07 35111 1030.00 1030.00 35112 1248.33 1248.33 35121 1233.33 1233.33 35122 1447.95 1447.95 35131 1048.06 1048.06 35132 1264.06 1264.06 35141 834.74 834.74 35142 993.07 993.07 35151 939.87 939.87 35152 1090.12 1090.12 35180 597.34 597.34 35182 1258.61 1258.61 35184 756.11 756.11 35188 641.55 641.55 35189 1191.03 1191.03 35190 556.09 556.09 35201 697.10 697.10 35206 570.86 570.86 35207 519.29 519.29 35211 1000.94 1000.94 35216 1315.92 1315.92 35221 1025.79 1025.79 35226 631.72 631.72 35231 865.08 865.08 35236 724.90 724.90 35241 1047.51 1047.51 35246 1128.14 1128.14 35251 1222.90 1222.90 35256 764.21 764.21 35261 765.57 765.57

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CODE NOTE NFAC FAC 26 TC

35266 635.90 635.90 35271 997.73 997.73 35276 1049.36 1049.36 35281 1167.46 1167.46 35286 703.33 703.33 35301 785.39 785.39 35302 817.61 817.61 35303 897.68 897.68 35304 934.15 934.15 35305 897.68 897.68 35306 335.34 335.34 35311 1122.40 1122.40 35321 669.14 669.14 35331 1091.73 1091.73 35341 1038.83 1038.83 35351 959.84 959.84 35355 781.18 781.18 35361 1181.22 1181.22 35363 1264.62 1264.62 35371 621.08 621.08 35372 744.34 744.34 35390 125.13 125.13 35400 113.62 113.62 35450 382.02 382.02 35452 267.23 267.23 35458 364.34 364.34 35460 242.53 242.53 35471 2745.56 413.48 35472 1854.38 281.68 35475 1813.50 370.86 35476 1378.96 236.91 35500 239.89 239.89 35501 1125.98 1125.98 35506 971.86 971.86 35508 994.76 994.76 35509 1096.40 1096.40 35510 928.85 928.85 35511 884.42 884.42 35512 910.49 910.49 35515 997.14 997.14 35516 876.63 876.63 35518 888.35 888.35 35521 948.44 948.44

CODE NOTE NFAC FAC 26 TC

35522 887.40 887.40 35523 930.42 930.42 35525 840.01 840.01 35526 1278.73 1278.73 35531 1500.02 1500.02 35533 1163.69 1163.69 35535 N.C. N.C. 35536 1298.54 1298.54 35537 1587.57 1587.57 35538 1772.34 1772.34 35539 1662.28 1662.28 35540 1852.97 1852.97 35556 1021.36 1021.36 35558 914.62 914.62 35560 1331.55 1331.55 35563 1033.16 1033.16 35565 986.06 986.06 35566 1223.75 1223.75 35570 N.C. N.C. 35571 1008.83 1008.83 35572 258.93 258.93 35583 1054.69 1054.69 35585 1245.47 1245.47 35587 1043.75 1043.75 35600 189.91 189.91 35601 1058.53 1058.53 35606 874.01 874.01 35612 684.90 684.90 35616 828.35 828.35 35621 832.44 832.44 35623 1019.54 1019.54 35626 1167.60 1167.60 35631 1393.93 1393.93 35632 1465.43 1465.43 35633 1582.42 1582.42 35634 1434.24 1434.24 35636 1228.02 1228.02 35637 1259.27 1259.27 35638 1279.24 1279.24 35642 753.94 753.94 35645 767.70 767.70 35646 1290.95 1290.95 35647 1166.68 1166.68

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CODE NOTE NFAC FAC 26 TC

35650 802.73 802.73 35654 1032.28 1032.28 35656 814.96 814.96 35661 816.51 816.51 35663 944.57 944.57 35665 886.80 886.80 35666 958.27 958.27 35671 843.82 843.82 35681 62.71 62.71 35682 268.17 268.17 35683 315.79 315.79 35685 150.91 150.91 35686 125.58 125.58 35691 741.38 741.38 35693 656.71 656.71 35694 774.53 774.53 35695 800.16 800.16 35697 112.17 112.17 35700 120.05 120.05 35701 398.44 398.44 35721 342.24 342.24 35741 372.04 372.04 35761 276.77 276.77 35800 353.23 353.23 35820 1268.08 1268.08 35840 457.86 457.86 35860 299.31 299.31 35870 953.74 953.74 35875 444.97 444.97 35876 708.25 708.25 35879 696.58 696.58 35881 774.69 774.69 35883 915.69 915.69 35884 972.19 972.19 35901 379.34 379.34 35903 431.04 431.04 35905 1308.67 1308.67 35907 1433.64 1433.64 36000 19.98 6.85 36002 129.47 83.99 36005 265.09 36.98 36010 518.88 93.19 36011 792.31 121.14

CODE NOTE NFAC FAC 26 TC

36012 677.52 135.57 36013 667.55 97.60 36014 662.49 116.86 36015 721.93 131.61 36100 429.52 121.68 36120 350.42 75.31 36140 400.71 77.42 36147 585.43 142.14 36148 184.52 37.96 36160 442.72 102.27 36200 531.38 116.43 36215 912.87 182.85 36216 990.58 205.45 36217 1678.00 246.83 36218 158.97 39.35 36221 1011.41 184.18 36222 1251.70 248.84 36223 1369.44 268.96 36224 1487.29 297.16 36225 1359.31 262.89 36226 1516.38 293.27 36227 216.59 92.57 36228 1041.05 188.53 36245 1031.62 188.68 36246 996.72 206.62 36247 1579.97 246.16 36248 134.56 39.35 36251 1275.20 239.23 36252 1398.25 311.53 36253 1951.72 332.77 36254 2030.17 358.93 36260 421.88 421.88 36261 257.60 257.60 36262 197.13 197.13 36299 REPORT REPORT REPORT 36400 18.48 13.36 36405 16.50 11.29 36406 13.03 6.54 36410 13.73 6.54 36415 2.39 2.39 36416 1.50 1.50 36420 34.21 34.21 36425 26.83 26.83

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CODE NOTE NFAC FAC 26 TC

36430 30.57 30.57 36440 36.50 36.50 36450 86.63 86.63 36455 93.27 93.27 36460 245.89 245.89 36468 P REPORT REPORT REPORT 36470 106.37 53.10 36471 129.07 74.25 36475 1475.62 253.22 36476 297.82 123.15 36478 1276.11 255.60 36479 302.87 125.02 36481 262.69 262.69 36500 131.74 131.74 36510 103.72 45.07 36511 64.73 64.73 36512 65.33 65.33 36513 66.96 66.96 36514 454.52 66.50 36515 1710.86 65.01 36516 2023.07 47.14 36522 1084.94 76.38 36555 211.96 93.90 36556 193.62 90.30 36557 682.77 225.38 36558 670.08 217.44 36560 931.00 267.76 36561 937.61 258.87 36563 920.50 271.73 36565 794.08 256.01 36566 2224.21 273.58 36568 250.25 71.12 36569 226.44 71.76 36570 958.81 229.16 36571 1008.54 234.08 36575 131.85 30.93 36576 276.60 141.67 36578 394.99 162.97 36580 200.06 52.36 36581 612.45 151.58 36582 843.16 222.85 36583 845.18 224.56 36584 198.12 54.68

CODE NOTE NFAC FAC 26 TC

36585 875.27 210.06 36589 124.18 102.14 36590 198.92 144.12 36591 16.36 16.36 36592 20.22 20.22 36593 28.28 28.28 36595 513.36 142.66 36596 113.22 35.42 36597 98.23 47.42 36598 92.10 53.02 36600 23.05 11.29 23.05 36620 36.11 36.11 36625 75.23 75.23 36640 86.94 86.94 36660 51.12 51.12 36680 44.59 44.59 36800 117.09 117.09 36810 155.71 155.71 36815 107.72 107.72 36818 503.27 503.27 36819 583.54 583.54 36820 585.35 585.35 36821 389.87 389.87 36823 916.23 916.23 36825 424.51 424.51 36830 484.03 484.03 36831 335.72 335.72 36832 427.24 427.24 36833 481.74 481.74 36835 331.94 331.94 36838 865.63 865.63 36860 129.51 75.26 36861 110.38 110.38 36870 1534.20 233.81 37140 969.53 969.53 37145 1057.82 1057.82 37160 909.66 909.66 37180 1034.43 1034.43 37181 1092.98 1092.98 37182 633.92 633.92 37183 302.50 302.50 37184 2042.85 342.18 37185 672.51 125.76

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CODE NOTE NFAC FAC 26 TC

37186 1387.09 189.89 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 167.68 167.68 37211 343.53 343.53 37212 303.30 303.30 37213 211.78 211.78 37214 124.70 124.70 37215 800.16 800.16 37216 714.29 714.29 37217 935.54 935.54 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 2357.81 377.25 37237 1023.74 184.27 37238 3457.89 276.63 37239 1719.03 120.33 37241 3823.59 382.36 37242 6448.75 386.93 37243 8141.92 488.52 37244 5691.56 569.16 37252 1237.63 81.56 37253 190.55 65.24

CODE NOTE NFAC FAC 26 TC

37500 511.39 511.39 37501 REPORT REPORT REPORT 37565 494.74 494.74 37600 518.22 518.22 37605 592.39 592.39 37606 391.36 391.36 37607 275.53 275.53 37609 214.66 141.40 37615 332.92 332.92 37616 772.88 772.88 37617 926.46 926.46 37618 270.49 270.49 37619 1411.82 1411.82 37650 370.11 370.11 37660 869.22 869.22 37700 185.35 185.35 37718 291.27 291.27 37722 345.51 345.51 37735 461.88 461.88 37760 451.99 451.99 37761 424.55 424.55 37765 324.73 324.73 37766 392.29 392.29 37780 189.06 189.06 37785 262.00 190.24 37788 954.54 954.54 37790 366.10 366.10 37799 REPORT REPORT REPORT 38100 731.34 731.34 38101 741.24 741.24 38102 186.69 186.69 38115 809.68 809.68 38120 697.67 697.67 38129 REPORT REPORT REPORT 38200 98.82 98.82 38204 P 65.00 65.00 38205 P 57.05 57.05 38206 P 57.34 57.34 38207 P 34.19 34.19 38208 P 21.82 21.82 38209 P 9.47 9.47 38210 P 60.89 60.89 38211 P 54.86 54.86

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CODE NOTE NFAC FAC 26 TC

38212 P 36.47 36.47 38213 P 9.47 9.47 38214 P 31.02 31.02 38215 P 36.47 36.47 38220 123.48 44.24 38221 136.13 56.49 38230 227.45 227.45 38232 157.99 157.99 38240 P 91.45 91.45 38241 P 88.10 88.10 38242 P 66.56 66.56 38243 97.80 97.80 38300 190.55 124.73 38305 316.06 316.06 38308 299.48 299.48 38380 387.64 387.64 38381 575.69 575.69 38382 466.33 466.33 38500 217.87 168.44 38505 92.66 55.57 38510 349.18 284.27 38520 312.29 312.29 38525 280.74 280.74 38530 363.30 363.30 38542 293.37 293.37 38550 320.49 320.49 38555 670.26 670.26 38562 476.77 476.77 38564 473.08 473.08 38570 381.21 381.21 38571 582.35 582.35 38572 666.22 666.22 38589 REPORT REPORT REPORT 38700 525.12 525.12 38720 863.96 863.96 38724 934.00 934.00 38740 447.59 447.59 38745 569.66 569.66 38746 194.16 194.16 38747 190.57 190.57 38760 562.55 562.55 38765 865.95 865.95 38770 571.93 571.93

CODE NOTE NFAC FAC 26 TC

38780 729.90 729.90 38790 60.53 60.53 38792 29.54 29.54 38794 219.49 219.49 38900 113.41 113.41 38999 REPORT REPORT REPORT 39000 343.91 343.91 39010 581.49 581.49 39200 634.92 634.92 39220 811.15 811.15 39401 276.01 276.01 39402 359.77 359.77 39499 REPORT REPORT REPORT 39501 577.68 577.68 39503 3911.67 3911.67 39540 588.39 588.39 39541 631.82 631.82 39545 629.33 629.33 39560 542.36 542.36 39561 836.99 836.99 39599 REPORT REPORT REPORT 40490 87.08 51.18 40500 347.34 258.46 40510 343.93 255.23 40520 362.51 260.17 40525 402.09 402.09 40527 475.54 475.54 40530 395.81 294.09 40650 304.71 206.72 40652 359.37 256.73 40654 415.37 305.59 40700 664.00 664.00 40701 785.80 785.80 40702 618.37 618.37 40720 729.63 729.63 40761 766.16 766.16 40799 REPORT REPORT REPORT 40800 134.49 91.39 40801 205.90 157.93 40804 144.21 93.17 40805 225.07 164.80 40806 72.16 24.60 40808 120.26 76.24

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CODE NOTE NFAC FAC 26 TC

40810 134.61 90.57 40812 189.49 140.96 40814 262.33 218.78 40816 276.44 228.06 40818 237.35 196.31 40819 203.82 168.05 40820 172.80 120.11 40830 171.43 115.24 40831 223.56 162.71 40840 572.36 459.78 40842 579.49 458.84 40843 728.16 577.14 40844 967.60 807.56 40845 1066.80 917.02 40899 REPORT REPORT REPORT 41000 112.57 80.05 41005 149.28 90.96 41006 251.29 188.14 41007 252.90 179.41 41008 253.05 193.74 41009 269.65 211.92 41010 138.98 78.94 41015 293.73 242.71 41016 305.17 250.48 41017 305.79 252.37 41018 352.93 293.39 41019 333.59 333.59 41100 119.29 80.22 41105 115.97 80.16 41108 97.80 64.95 41110 140.58 94.30 41112 224.91 180.00 41113 248.04 199.70 41114 458.82 458.82 41115 160.13 106.29 41116 215.62 157.58 41120 765.17 765.17 41130 889.17 889.17 41135 1465.22 1465.22 41140 1590.93 1590.93 41145 1889.24 1889.24 41150 1499.20 1499.20 41153 1612.07 1612.07

CODE NOTE NFAC FAC 26 TC

41155 1967.64 1967.64 41250 151.26 98.29 41251 170.57 117.23 41252 214.02 153.62 41500 337.66 337.66 41510 318.69 318.69 41512 446.56 446.56 41520 231.82 186.22 41530 2253.30 292.70 41599 REPORT REPORT REPORT 41800 143.71 87.65 41805 144.50 113.26 41806 218.32 180.22 41820 49.00 49.00 41821 18.00 18.00 41822 196.61 127.54 41823 282.40 227.73 41825 138.41 97.01 41826 178.76 142.13 41827 283.37 215.70 41828 215.83 164.66 41830 261.68 204.90 41850 26.00 26.00 41870 50.00 50.00 41872 245.00 188.48 41874 251.00 185.69 41899 REPORT REPORT REPORT 42000 113.97 73.96 42100 105.77 78.79 42104 136.78 97.47 42106 174.10 132.32 42107 316.71 247.32 42120 663.22 663.22 42140 168.12 111.82 42145 481.20 481.20 42160 176.31 113.67 42180 171.19 132.74 42182 232.82 194.99 42200 650.22 650.22 42205 667.54 667.54 42210 785.82 785.82 42215 523.80 523.80 42220 421.37 421.37

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CODE NOTE NFAC FAC 26 TC

42225 729.65 729.65 42226 707.16 707.16 42227 697.59 697.59 42235 570.24 570.24 42260 607.08 501.02 42280 110.33 76.48 42281 143.24 110.68 42299 REPORT REPORT REPORT 42300 147.57 110.38 42305 311.32 311.32 42310 115.32 89.89 42320 174.90 129.22 42330 164.82 118.62 42335 255.24 188.14 42340 330.23 247.44 42400 75.33 43.10 42405 217.06 164.97 42408 322.83 238.18 42409 228.52 163.78 42410 451.07 451.07 42415 809.28 809.28 42420 928.43 928.43 42425 614.24 614.24 42426 993.02 993.02 42440 333.88 333.88 42450 323.08 261.05 42500 307.13 248.84 42505 400.56 333.59 42507 373.18 373.18 42509 624.92 624.92 42510 460.69 460.69 42550 119.63 47.68 42600 342.30 255.15 42650 58.12 43.10 42660 75.41 56.81 42665 208.59 150.62 42699 REPORT REPORT REPORT 42700 132.62 97.87 42720 317.22 284.04 42725 581.26 581.26 42800 110.88 81.49 42804 149.01 85.76 42806 167.69 100.09

CODE NOTE NFAC FAC 26 TC

42808 163.46 120.36 42809 122.66 92.89 42810 279.02 206.81 42815 401.48 401.48 42820 212.03 212.03 42821 222.60 222.60 42825 190.85 190.85 42826 184.39 184.39 42830 150.61 150.61 42831 162.77 162.77 42835 132.07 132.07 42836 177.84 177.84 42842 661.27 661.27 42844 946.62 946.62 42845 1519.60 1519.60 42860 136.27 136.27 42870 421.46 421.46 42890 937.22 937.22 42892 1217.61 1217.61 42894 1565.68 1565.68 42900 253.23 253.23 42950 587.88 587.88 42953 749.63 749.63 42955 550.27 550.27 42960 123.39 123.39 42961 306.63 306.63 42962 378.16 378.16 42970 280.59 280.59 42971 333.20 333.20 42972 378.71 378.71 42999 REPORT REPORT REPORT 43020 391.03 391.03 43030 380.50 380.50 43045 947.33 947.33 43100 451.53 451.53 43101 740.68 740.68 43107 1825.81 1825.81 43108 2742.95 2742.95 43112 1956.78 1956.78 43113 2709.67 2709.67 43116 3089.60 3089.60 43117 1780.04 1780.04 43118 2301.34 2301.34

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CODE NOTE NFAC FAC 26 TC

43121 1857.24 1857.24 43122 1807.52 1807.52 43123 2769.27 2769.27 43124 2371.57 2371.57 43130 571.01 571.01 43135 981.65 981.65 43180 460.23 508.00 43191 104.66 104.66 43192 124.69 124.69 43193 148.40 148.40 43194 134.15 134.15 43195 148.70 148.70 43196 163.21 163.21 43197 152.99 65.79 43198 170.59 78.47 43200 166.79 76.54 43201 208.86 94.07 43202 219.36 82.90 43204 160.54 160.54 43205 161.47 161.47 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 112.13 112.13 43216 131.99 103.77 43217 292.42 122.17 43220 91.86 91.86 43226 102.01 102.01 43227 150.90 150.90 43229 606.36 169.78 43231 136.69 136.69 43232 190.75 190.75 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 263.37 123.20 43240 284.92 284.92 43241 111.85 111.85

CODE NOTE NFAC FAC 26 TC

43242 303.84 303.84 43243 192.18 192.18 43244 212.82 212.82 43245 135.10 135.10 43246 180.44 180.44 43247 144.40 144.40 43248 135.82 135.82 43249 125.03 125.03 43250 135.68 135.68 43251 156.63 156.63 43252 N.C. N.C. 43253 224.65 224.65 43254 233.30 233.30 43255 203.27 203.27 43257 219.93 219.93 43259 216.98 216.98 43260 249.23 249.23 43261 262.07 262.07 43262 307.74 307.74 43263 303.23 303.23 43264 369.24 369.24 43265 414.62 414.62 43266 193.08 193.08 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 923.75 923.75 43280 747.95 747.95 43281 1207.08 1207.08 43282 1357.36 1357.36 43283 135.59 135.59 43289 REPORT REPORT REPORT 43300 453.86 453.86 43305 805.07 805.07 43310 1106.21 1106.21 43312 1217.06 1217.06 43313 1968.46 1968.46 43314 2100.60 2100.60 43320 927.61 927.61

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CODE NOTE NFAC FAC 26 TC

43325 914.82 914.82 43327 684.75 684.75 43328 1006.71 1006.71 43330 899.11 899.11 43331 956.37 956.37 43332 980.12 980.12 43333 980.12 980.12 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 908.56 908.56 43341 983.75 983.75 43351 920.04 920.04 43352 750.82 750.82 43360 1619.14 1619.14 43361 1802.01 1802.01 43400 1030.49 1030.49 43401 1023.59 1023.59 43405 991.02 991.02 43410 680.44 680.44 43415 1171.86 1171.86 43420 678.78 678.78 43425 1008.07 1008.07 43450 121.53 64.16 43453 234.22 69.26 43460 157.37 157.37 43496 REPORT REPORT REPORT 43499 REPORT REPORT REPORT 43500 509.00 509.00 43501 900.23 900.23 43502 1036.41 1036.41 43510 648.36 648.36 43520 484.93 484.93 43605 548.29 548.29 43610 659.15 659.15 43611 806.70 806.70 43620 1328.85 1328.85 43621 1454.85 1454.85 43622 1485.29 1485.29 43631 993.29 993.29 43632 1257.56 1257.56

CODE NOTE NFAC FAC 26 TC

43633 1204.55 1204.55 43634 1325.77 1325.77 43635 79.96 79.96 43640 770.98 770.98 43641 781.34 781.34 43644 P 1179.12 1179.12 43645 P 1263.44 1263.44 43647 REPORT REPORT REPORT 43648 REPORT REPORT REPORT 43651 446.28 446.28 43652 529.20 529.20 43653 377.61 377.61 43659 REPORT REPORT REPORT 43752 29.50 29.50 43753 16.91 16.91 43754 66.39 25.52 43755 100.89 47.68 43756 184.44 43.01 43757 236.86 61.87 43760 145.11 37.92 43761 89.88 76.86 43770 P 760.10 760.10 43771 867.68 867.68 43772 652.79 652.79 43773 867.67 867.67 43774 656.58 656.58 43775 969.41 969.41 43800 622.19 622.19 43810 661.51 661.51 43820 829.17 829.17 43825 864.88 864.88 43830 455.89 455.89 43831 391.53 391.53 43832 710.69 710.69 43840 843.62 843.62 43842 P 834.21 834.21 43843 P 838.72 838.72 43845 1298.55 1298.55 43846 P 1082.57 1082.57 43847 P 1201.41 1201.41 43848 1309.05 1309.05 43850 1097.55 1097.55 43855 1150.74 1150.74

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CODE NOTE NFAC FAC 26 TC

43860 1111.02 1111.02 43865 1164.40 1164.40 43870 458.49 458.49 43880 1092.50 1092.50 43881 REPORT REPORT REPORT 43882 REPORT REPORT REPORT 43886 219.03 219.03 43887 212.83 212.83 43888 301.58 301.58 43999 REPORT REPORT REPORT 44005 729.00 729.00 44010 570.31 570.31 44015 102.26 102.26 44020 633.06 633.06 44021 636.84 636.84 44025 645.20 645.20 44050 634.84 634.84 44055 976.47 976.47 44100 82.06 82.06 44110 549.97 549.97 44111 647.24 647.24 44120 789.78 789.78 44121 172.71 172.71 44125 786.18 786.18 44126 1587.70 1587.70 44127 1848.22 1848.22 44128 175.14 175.14 44130 810.08 810.08 44132 P REPORT REPORT REPORT 44133 P REPORT REPORT REPORT 44135 P REPORT REPORT REPORT 44136 P REPORT REPORT REPORT 44137 REPORT REPORT REPORT 44139 86.21 86.21 44140 919.35 919.35 44141 1135.83 1135.83 44143 1084.04 1084.04 44144 1120.40 1120.40 44145 1146.56 1146.56 44146 1358.83 1358.83 44147 1195.09 1195.09 44150 1196.89 1196.89 44151 1367.30 1367.30

CODE NOTE NFAC FAC 26 TC

44155 1340.36 1340.36 44156 1474.73 1474.73 44157 1500.71 1500.71 44158 1539.30 1539.30 44160 834.99 834.99 44180 633.99 633.99 44186 448.92 448.92 44187 758.25 758.25 44188 833.72 833.72 44202 952.06 952.06 44203 172.11 172.11 44204 1062.87 1062.87 44205 929.86 929.86 44206 1204.41 1204.41 44207 1264.16 1264.16 44208 1379.24 1379.24 44210 1230.15 1230.15 44211 1513.92 1513.92 44212 1414.02 1414.02 44213 135.57 135.57 44227 1147.58 1147.58 44238 REPORT REPORT REPORT 44300 558.77 558.77 44310 713.53 713.53 44312 386.24 386.24 44314 680.15 680.15 44316 931.24 931.24 44320 801.27 801.27 44322 649.68 649.68 44340 391.19 391.19 44345 706.80 706.80 44346 770.93 770.93 44360 112.82 112.82 44361 124.15 124.15 44363 147.97 147.97 44364 157.85 157.85 44365 140.53 140.53 44366 186.56 186.56 44369 189.79 189.79 44370 205.12 205.12 44372 183.72 183.72 44373 147.34 147.34 44376 217.72 217.72

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CODE NOTE NFAC FAC 26 TC

44377 230.37 230.37 44378 296.68 296.68 44379 317.10 317.10 44380 49.51 49.51 44381 REPORT REPORT REPORT 44382 59.04 59.04 44384 REPORT REPORT REPORT 44385 172.31 76.80 44386 266.98 90.21 44388 245.99 119.18 44389 301.98 132.96 44390 339.74 160.73 44391 395.66 182.00 44392 323.45 158.23 44394 378.39 183.94 44401 REPORT REPORT REPORT 44402 REPORT REPORT REPORT 44403 REPORT REPORT REPORT 44404 REPORT REPORT REPORT 44405 REPORT REPORT REPORT 44406 REPORT REPORT REPORT 44407 REPORT REPORT REPORT 44408 REPORT REPORT REPORT 44500 18.77 18.77 44602 880.12 880.12 44603 1005.61 1005.61 44604 714.41 714.41 44605 885.13 885.13 44615 717.13 717.13 44620 560.21 560.21 44625 675.09 675.09 44626 1105.02 1105.02 44640 958.19 958.19 44650 998.35 998.35 44660 926.84 926.84 44661 1080.41 1080.41 44680 695.90 695.90 44700 702.45 702.45 44701 119.20 119.20 44705 N.C. N.C. 44715 P REPORT REPORT REPORT 44720 P 186.22 186.22 44721 P 274.07 274.07

CODE NOTE NFAC FAC 26 TC

44799 REPORT REPORT REPORT 44800 520.32 520.32 44820 557.94 557.94 44850 498.87 498.87 44899 REPORT REPORT REPORT 44900 490.81 490.81 44950 439.85 439.85 44955 60.06 60.06 44960 562.94 562.94 44970 403.40 403.40 44979 REPORT REPORT REPORT 45000 265.92 265.92 45005 183.66 107.99 45020 341.07 341.07 45100 190.28 190.28 45108 237.84 237.84 45110 1264.90 1264.90 45111 742.59 742.59 45112 1297.16 1297.16 45113 1332.65 1332.65 45114 1207.35 1207.35 45116 1090.15 1090.15 45119 1332.81 1332.81 45120 1064.52 1064.52 45121 1171.04 1171.04 45123 739.70 739.70 45126 1965.96 1965.96 45130 727.93 727.93 45135 874.60 874.60 45136 1244.75 1244.75 45150 264.69 264.69 45160 670.09 670.09 45171 440.21 440.21 45172 603.32 603.32 45190 452.11 452.11 45300 72.66 33.19 45303 613.63 55.41 45305 120.76 52.57 45307 138.88 65.55 45308 117.60 55.18 45309 143.50 68.45 45315 148.49 74.33 45317 140.19 78.09

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CODE NOTE NFAC FAC 26 TC

45320 142.85 74.04 45321 68.22 68.22 45327 77.93 77.93 45330 100.56 44.66 45331 130.91 53.69 45332 211.38 78.99 45333 214.21 78.38 45334 117.88 117.88 45335 166.90 65.59 45337 101.94 101.94 45338 234.80 101.39 45340 295.79 81.96 45341 112.18 112.18 45342 170.97 170.97 45346 REPORT REPORT REPORT 45347 REPORT REPORT REPORT 45349 REPORT REPORT REPORT 45350 REPORT REPORT REPORT 45378 298.64 155.38 45379 376.43 194.09 45380 356.70 186.45 45381 347.21 176.04 45382 473.56 237.59 45384 349.45 194.71 45385 400.29 221.04 45386 513.67 190.83 45388 REPORT REPORT REPORT 45389 REPORT REPORT REPORT 45390 REPORT REPORT REPORT 45391 214.84 214.84 45392 269.79 269.79 45393 REPORT REPORT REPORT 45395 1366.98 1366.98 45397 1474.68 1474.68 45398 REPORT REPORT REPORT 45399 REPORT REPORT REPORT 45400 789.90 789.90 45402 1055.18 1055.18 45499 REPORT REPORT REPORT 45500 338.27 338.27 45505 360.23 360.23 45520 81.94 27.34 45540 716.10 716.10

CODE NOTE NFAC FAC 26 TC

45541 608.97 608.97 45550 996.29 996.29 45560 489.39 489.39 45562 718.90 718.90 45563 1079.14 1079.14 45800 800.13 800.13 45805 943.82 943.82 45820 807.92 807.92 45825 974.19 974.19 45900 129.23 129.23 45905 114.64 114.64 45910 135.87 135.87 45915 222.51 154.29 45990 75.22 75.22 45999 REPORT REPORT REPORT 46020 165.12 150.24 46030 82.91 59.67 46040 329.29 271.30 46045 260.81 260.81 46050 119.57 63.74 46060 287.67 287.67 46070 144.17 144.17 46080 152.85 108.42 46083 116.75 70.24 46200 248.21 203.61 46220 123.18 77.42 46221 158.68 124.33 46230 177.24 116.36 46250 289.11 206.16 46255 328.50 234.71 46257 260.61 260.61 46258 283.54 283.54 46260 301.14 301.14 46261 335.40 335.40 46262 352.52 352.52 46270 301.90 242.46 46275 314.21 260.23 46280 289.63 289.63 46285 297.66 245.63 46288 339.00 339.00 46320 117.07 73.93 46500 130.26 84.17 46505 180.70 150.87

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CODE NOTE NFAC FAC 26 TC

46600 61.15 26.73 46601 REPORT REPORT REPORT 46604 351.53 47.60 46606 146.47 49.27 46607 REPORT REPORT REPORT 46608 164.68 57.08 46610 158.81 56.17 46611 129.89 59.81 46612 200.15 73.31 46614 97.75 52.78 46615 113.85 74.77 46700 416.78 416.78 46705 335.67 335.67 46706 112.92 112.92 46707 336.08 336.08 46710 717.45 717.45 46712 1496.97 1496.97 46715 335.40 335.40 46716 731.59 731.59 46730 1204.69 1204.69 46735 1426.34 1426.34 46740 1334.65 1334.65 46742 1602.07 1602.07 46744 2307.89 2307.89 46746 2599.53 2599.53 46748 2624.92 2624.92 46750 490.30 490.30 46751 426.92 426.92 46753 381.41 381.41 46754 184.44 140.30 46760 697.51 697.51 46761 620.52 620.52 46762 586.42 586.42 46900 145.04 94.31 46910 153.09 89.34 46916 154.60 97.86 46917 332.75 91.17 46922 163.47 90.22 46924 356.90 123.88 46930 150.87 108.78 46940 136.32 100.10 46942 125.45 89.41 46945 178.34 145.42

CODE NOTE NFAC FAC 26 TC

46946 197.00 153.29 46947 252.89 252.89 46999 REPORT REPORT REPORT 47000 210.36 73.02 47001 74.03 74.03 47010 778.25 778.25 47015 741.04 741.04 47100 561.48 561.48 47120 1593.04 1593.04 47122 2369.10 2369.10 47125 2126.38 2126.38 47130 2285.40 2285.40 47133 N.C. N.C. 47135 P 3364.36 3364.36 47140 P 2363.74 2363.74 47141 P 2805.17 2805.17 47142 P 3081.39 3081.39 47143 P REPORT REPORT REPORT 47144 P REPORT REPORT REPORT 47145 P REPORT REPORT REPORT 47146 P 234.84 234.84 47147 P 273.77 273.77 47300 726.11 726.11 47350 902.66 902.66 47360 1218.11 1218.11 47361 2076.67 2076.67 47362 919.92 919.92 47370 854.62 854.62 47371 859.49 859.49 47379 REPORT REPORT REPORT 47380 994.05 994.05 47381 1015.98 1015.98 47382 611.34 611.34 47383 6734.62 435.06 47399 REPORT REPORT REPORT 47400 1428.90 1428.90 47420 909.44 909.44 47425 909.31 909.31 47460 833.64 833.64 47480 552.55 552.55 47490 386.36 386.36 47531 326.57 83.47 47532 717.94 187.67

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CODE NOTE NFAC FAC 26 TC

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 3973.22 285.28 47539 4339.58 385.79 47540 4510.00 460.92 47541 1035.68 245.77 47542 453.90 117.06 47543 1172.97 148.15 47544 711.27 183.22 47550 117.72 117.72 47552 243.55 243.55 47553 241.63 241.63 47554 365.07 365.07 47555 289.34 289.34 47556 326.88 326.88 47562 502.49 502.49 47563 517.83 517.83 47564 598.78 598.78 47570 533.37 533.37 47579 REPORT REPORT REPORT 47600 680.30 680.30 47605 667.85 667.85 47610 849.33 849.33 47612 846.38 846.38 47620 926.27 926.27 47700 712.51 712.51 47701 1190.61 1190.61 47711 1046.61 1046.61 47712 1353.15 1353.15 47715 864.30 864.30 47720 742.14 742.14 47721 878.56 878.56 47740 851.50 851.50 47741 972.60 972.60 47760 1398.67 1398.67 47765 1796.98 1796.98 47780 1521.59 1521.59 47785 1963.68 1963.68 47800 1059.16 1059.16 47801 718.71 718.71

CODE NOTE NFAC FAC 26 TC

47802 991.22 991.22 47900 913.62 913.62 47999 REPORT REPORT REPORT 48000 1251.19 1251.19 48001 1567.36 1567.36 48020 752.55 752.55 48100 574.28 574.28 48102 389.35 188.99 48105 1906.31 1906.31 48120 720.87 720.87 48140 1031.39 1031.39 48145 1074.92 1074.92 48146 1218.57 1218.57 48148 802.87 802.87 48150 2127.97 2127.97 48152 1966.22 1966.22 48153 2125.85 2125.85 48154 1977.29 1977.29 48155 1170.42 1170.42 48160 P REPORT REPORT REPORT 48400 75.05 75.05 48500 728.11 728.11 48510 698.83 698.83 48520 707.76 707.76 48540 883.80 883.80 48545 859.72 859.72 48547 1156.30 1156.30 48548 1112.00 1112.00 48550 N.C. N.C. 48551 P REPORT REPORT REPORT 48552 P 160.66 160.66 48554 P 1655.04 1655.04 48556 793.64 793.64 48999 REPORT REPORT REPORT 49000 530.05 530.05 49002 643.82 643.82 49010 619.28 619.28 49020 1044.59 1044.59 49040 647.84 647.84 49060 730.53 730.53 49062 517.40 517.40 49082 141.06 58.84 49083 266.58 90.53

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CODE NOTE NFAC FAC 26 TC

49084 82.53 82.53 49180 134.08 65.86 49185 877.70 107.17 49203 788.40 788.40 49204 1004.32 1004.32 49205 1148.64 1148.64 49215 1509.17 1509.17 49220 664.20 664.20 49250 395.74 395.74 49255 530.37 530.37 49320 229.33 229.33 49321 240.59 240.59 49322 262.07 262.07 49323 439.37 439.37 49324 265.60 265.60 49325 285.83 285.83 49326 129.57 129.57 49327 109.19 109.19 49329 REPORT REPORT REPORT 49400 139.03 72.37 49402 570.36 570.36 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 313.99 313.99 49421 270.83 270.83 49422 271.36 271.36 49423 461.95 57.24 49424 126.27 30.14 49425 527.35 527.35 49426 449.17 449.17 49427 34.56 34.56 49428 306.30 306.30 49429 321.13 321.13 49435 83.34 83.34 49436 126.16 126.16 49440 863.77 171.46 49441 1023.77 186.43 49442 834.35 154.52 49446 854.78 121.38

CODE NOTE NFAC FAC 26 TC

49450 600.97 49.16 49451 635.69 67.83 49452 776.18 105.87 49460 638.50 34.61 49465 132.18 22.89 49491 511.90 511.90 49492 638.27 638.27 49495 274.14 274.14 49496 407.58 407.58 49500 272.11 272.11 49501 403.84 403.84 49505 352.07 352.07 49507 432.97 432.97 49520 430.24 430.24 49521 524.46 524.46 49525 388.95 388.95 49540 460.31 460.31 49550 391.62 391.62 49553 427.61 427.61 49555 407.07 407.07 49557 493.61 493.61 49560 506.09 506.09 49561 634.71 634.71 49565 521.89 521.89 49566 641.27 641.27 49568 189.96 189.96 49570 277.80 277.80 49572 326.54 326.54 49580 212.29 212.29 49582 319.12 319.12 49585 297.68 297.68 49587 352.65 352.65 49590 387.74 387.74 49600 501.10 501.10 49605 3305.50 3305.50 49606 785.37 785.37 49610 473.92 473.92 49611 435.47 435.47 49650 291.59 291.59 49651 375.79 375.79 49652 562.22 562.22 49653 701.53 701.53 49654 644.77 644.77

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CODE NOTE NFAC FAC 26 TC

49655 776.28 776.28 49656 647.33 647.33 49657 934.27 934.27 49659 REPORT REPORT REPORT 49900 558.66 558.66 49904 1072.07 1072.07 49905 252.79 252.79 49906 REPORT REPORT REPORT 49999 REPORT REPORT REPORT 50010 505.30 505.30 50020 723.49 723.49 50040 670.88 670.88 50045 668.18 668.18 50060 832.53 832.53 50065 857.05 857.05 50070 870.16 870.16 50075 1067.44 1067.44 50080 637.82 637.82 50081 934.12 934.12 50100 700.49 700.49 50120 693.89 693.89 50125 727.22 727.22 50130 754.16 754.16 50135 819.99 819.99 50200 106.82 106.82 50205 495.69 495.69 50220 747.59 747.59 50225 867.03 867.03 50230 932.43 932.43 50234 949.02 949.02 50236 1073.39 1073.39 50240 961.45 961.45 50250 894.45 894.45 50280 688.72 688.72 50290 648.29 648.29 50300 P 219.00 219.00 50320 P 961.34 961.34 50323 P REPORT REPORT REPORT 50325 P REPORT REPORT REPORT 50327 P 143.71 143.71 50328 P 126.30 126.30 50329 P 122.38 122.38 50340 603.54 603.54

CODE NOTE NFAC FAC 26 TC

50360 P 1620.22 1620.22 50365 P 1818.85 1818.85 50370 754.28 754.28 50380 P 1227.41 1227.41 50382 1076.86 212.79 50384 965.35 193.46 50385 1030.22 178.85 50386 664.76 135.61 50387 512.17 76.88 50389 318.75 42.62 50390 72.10 72.10 50391 96.77 72.66 50395 135.19 135.19 50396 87.69 87.69 50400 843.37 843.37 50405 1014.40 1014.40 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 834.05 834.05 50520 755.13 755.13 50525 962.47 962.47 50526 972.38 972.38 50540 840.37 840.37 50541 673.90 673.90 50542 852.51 852.51 50543 1087.31 1087.31 50544 919.24 919.24 50545 984.62 984.62 50546 875.32 875.32 50547 1080.49 1080.49 50548 992.75 992.75 50549 REPORT REPORT REPORT 50551 280.08 218.74 50553 291.45 231.00 50555 321.87 254.28 50557 323.80 257.10 50561 365.52 293.48 50562 435.29 435.29 50570 365.23 365.23

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CODE NOTE NFAC FAC 26 TC

50572 396.87 396.87 50574 421.98 421.98 50575 531.84 531.84 50576 419.93 419.93 50580 452.27 452.27 50590 696.85 424.52 50592 3524.46 280.19 50593 3654.98 344.66 50600 680.94 680.94 50605 672.03 672.03 50606 462.55 136.64 50610 702.66 702.66 50620 661.24 661.24 50630 645.44 645.44 50650 753.84 753.84 50660 835.08 835.08 50684 153.40 38.20 50686 95.60 67.70 50688 61.36 61.36 50690 79.56 52.45 50693 929.70 189.47 50694 1022.26 244.83 50695 1245.84 309.96 50700 682.90 682.90 50705 1503.69 175.18 50706 670.58 162.21 50715 826.03 826.03 50722 720.00 720.00 50725 791.63 791.63 50727 368.74 368.74 50728 509.25 509.25 50740 798.52 798.52 50750 845.53 845.53 50760 799.51 799.51 50770 844.52 844.52 50780 797.65 797.65 50782 807.42 807.42 50783 838.45 838.45 50785 878.85 878.85 50800 669.18 669.18 50810 913.61 913.61 50815 887.35 887.35 50820 951.79 951.79

CODE NOTE NFAC FAC 26 TC

50825 1202.85 1202.85 50830 1314.18 1314.18 50840 895.34 895.34 50845 907.64 907.64 50860 692.45 692.45 50900 611.88 611.88 50920 641.68 641.68 50930 793.53 793.53 50940 638.41 638.41 50945 724.96 724.96 50947 1024.57 1024.57 50948 932.14 932.14 50949 REPORT REPORT REPORT 50951 291.93 227.91 50953 305.93 249.94 50955 353.07 272.36 50957 329.80 263.97 50961 297.00 235.64 50970 276.53 276.53 50972 266.80 266.80 50974 347.94 347.94 50976 345.72 345.72 50980 265.10 265.10 51020 338.55 338.55 51030 338.81 338.81 51040 223.74 223.74 51045 340.40 340.40 51050 342.54 342.54 51060 423.88 423.88 51065 419.39 419.39 51080 297.37 297.37 51100 48.27 28.90 51101 99.95 38.31 51102 248.27 159.66 51500 460.37 460.37 51520 433.22 433.22 51525 624.67 624.67 51530 562.33 562.33 51535 577.26 577.26 51550 691.28 691.28 51555 917.60 917.60 51565 942.97 942.97 51570 1072.39 1072.39

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CODE NOTE NFAC FAC 26 TC

51575 1329.10 1329.10 51580 1383.37 1383.37 51585 1539.00 1539.00 51590 1406.03 1406.03 51595 1595.67 1595.67 51596 1713.12 1713.12 51597 1658.44 1658.44 51600 161.56 33.98 51605 28.53 28.53 51610 90.44 49.22 51700 69.55 33.98 51701 52.53 20.91 51702 67.43 23.09 51703 113.63 61.88 51705 91.65 51.41 51710 130.53 72.05 51715 224.49 146.48 51720 91.17 62.29 51725 188.20 188.20 56.35 131.85

51726 265.31 265.31 64.10 201.21

51727 244.87 244.87 89.57 155.30

51728 244.57 244.57 88.34 156.23

51729 262.73 262.73 104.67 158.06

51736 37.97 37.97 22.25 15.72

51741 46.44 46.44 32.18 14.26

51784 163.16 163.16 57.22 105.94

51785 176.28 176.28 56.94 119.34

51792 197.34 197.34 41.22 156.12

51797 144.95 144.95 34.85 110.10

51798 16.24 16.24 51800 759.55 759.55 51820 799.61 799.61 51840 478.30 478.30 51841 569.73 569.73 51845 430.39 430.39 51860 528.84 528.84 51865 647.53 647.53 51880 343.44 343.44 51900 602.51 602.51 51920 566.14 566.14 51925 H 801.11 801.11 51940 1171.76 1171.76 51960 1006.99 1006.99

CODE NOTE NFAC FAC 26 TC

51980 518.10 518.10 51990 548.23 548.23 51992 595.82 595.82 51999 REPORT REPORT REPORT 52000 162.82 93.59 52001 296.68 212.10 52005 231.95 101.39 52007 485.56 127.31 52010 361.40 127.03 52204 408.82 107.27 52214 617.21 152.39 52224 814.68 130.59 52234 182.38 182.38 52235 223.07 223.07 52240 374.19 374.19 52250 179.01 179.01 52260 154.59 154.59 52265 389.49 122.49 52270 359.10 140.16 52275 495.85 191.70 52276 196.43 196.43 52277 241.40 241.40 52281 259.58 118.99 52282 248.79 248.79 52283 218.89 148.01 52285 220.85 143.73 52287 264.63 139.72 52290 180.68 180.68 52300 208.75 208.75 52301 218.75 218.75 52305 206.96 206.96 52310 204.79 116.53 52315 367.32 211.98 52317 865.30 269.45 52318 352.37 352.37 52320 182.88 182.88 52325 238.13 238.13 52327 285.05 204.55 52330 720.29 204.20 52332 346.49 119.57 52334 197.67 197.67 52341 242.08 242.08 52342 260.38 260.38

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CODE NOTE NFAC FAC 26 TC

52343 286.42 286.42 52344 309.18 309.18 52345 327.79 327.79 52346 366.14 366.14 52351 232.64 232.64 52352 273.07 273.07 52353 314.31 314.31 52354 290.55 290.55 52355 346.36 346.36 52356 337.38 337.38 52400 404.68 404.68 52402 199.23 199.23 52441 1089.41 202.74 52442 851.58 71.96 52450 341.01 341.01 52500 400.39 400.39 52601 601.27 601.27 52630 336.54 336.54 52640 294.21 294.21 52647 2023.59 486.67 52648 2054.47 519.58 52649 734.72 734.72 52700 317.32 317.32 53000 111.16 111.16 53010 215.07 215.07 53020 71.76 71.76 53025 50.09 50.09 53040 290.64 290.64 53060 135.79 116.74 53080 346.64 346.64 53085 476.16 476.16 53200 114.86 103.84 53210 564.97 564.97 53215 680.56 680.56 53220 330.22 330.22 53230 441.47 441.47 53235 465.74 465.74 53240 313.06 313.06 53250 287.41 287.41 53260 151.42 129.98 53265 168.81 135.45 53270 155.07 136.01 53275 196.51 196.51

CODE NOTE NFAC FAC 26 TC

53400 586.01 586.01 53405 639.35 639.35 53410 716.84 716.84 53415 817.08 817.08 53420 599.75 599.75 53425 688.82 688.82 53430 696.93 696.93 53431 845.24 845.24 53440 633.57 633.57 53442 558.36 558.36 53444 582.39 582.39 53445 641.16 641.16 53446 472.55 472.55 53447 598.33 598.33 53448 937.86 937.86 53449 446.46 446.46 53450 297.28 297.28 53460 334.20 334.20 53500 547.49 547.49 53502 355.32 355.32 53505 355.45 355.45 53510 468.42 468.42 53515 586.34 586.34 53520 408.18 408.18 53600 66.64 47.58 53601 65.51 40.94 53605 48.09 48.09 53620 98.50 64.55 53621 94.13 55.86 53660 58.17 31.75 53661 57.89 30.82 53665 28.32 28.32 53850 2401.12 429.56 53852 2297.67 467.35 53855 487.72 86.57 53860 1237.12 193.24 53899 REPORT REPORT REPORT 54000 125.10 80.65 54001 152.10 100.58 54015 228.66 228.66 54050 89.53 69.57 54055 85.40 63.07 54056 93.42 72.58

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CODE NOTE NFAC FAC 26 TC

54057 105.89 66.58 54060 144.46 92.43 54065 152.70 112.20 54100 141.61 85.76 54105 217.12 159.06 54110 458.99 458.99 54111 587.12 587.12 54112 688.72 688.72 54115 332.50 306.60 54120 458.93 458.93 54125 591.98 591.98 54130 874.26 874.26 54135 1109.28 1109.28 54150 144.79 73.32 54160 185.57 109.84 54161 144.20 144.20 54162 216.03 142.19 54163 159.46 159.46 54164 140.84 140.84 54200 85.91 62.97 54205 394.98 394.98 54220 171.44 103.17 54230 72.72 58.72 54231 104.98 86.81 54235 66.69 55.80 54240 74.72 74.72 48.91 25.81

54250 91.60 91.60 82.70 8.90

54300 479.07 479.07 54304 561.43 561.43 54308 493.34 493.34 54312 627.63 627.63 54316 744.54 744.54 54318 501.97 501.97 54322 584.21 584.21 54324 727.48 727.48 54326 702.35 702.35 54328 692.03 692.03 54332 751.23 751.23 54336 856.46 856.46 54340 425.38 425.38 54344 720.36 720.36 54348 760.50 760.50 54352 1082.35 1082.35

CODE NOTE NFAC FAC 26 TC

54360 538.37 538.37 54380 592.28 592.28 54385 721.93 721.93 54390 854.76 854.76 54400 P 393.91 393.91 54401 P 481.75 481.75 54405 P 592.93 592.93 54406 534.91 534.91 54408 P 574.28 574.28 54410 P 677.61 677.61 54411 P 741.65 741.65 54415 P 385.53 385.53 54416 P 513.97 513.97 54417 P 651.13 651.13 54420 520.21 520.21 54430 471.01 471.01 54435 306.74 306.74 54437 591.34 591.34 54438 1191.32 1191.32 54440 372.41 372.41 54450 56.97 43.85 54500 54.87 54.87 54505 158.77 158.77 54512 393.95 393.95 54520 241.08 241.08 54522 432.50 432.50 54530 403.08 403.08 54535 536.13 536.13 54550 357.25 357.25 54560 501.40 501.40 54600 330.47 330.47 54620 222.67 222.67 54640 340.66 340.66 54650 501.19 501.19 54660 P 261.77 261.77 54670 300.31 300.31 54680 584.03 584.03 54690 473.15 473.15 54692 568.40 568.40 54699 REPORT REPORT REPORT 54700 157.61 157.61 54800 95.82 95.82 54830 268.90 268.90

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CODE NOTE NFAC FAC 26 TC

54840 238.06 238.06 54860 304.45 304.45 54861 412.61 412.61 54865 259.13 259.13 54900 539.26 539.26 54901 789.43 789.43 55000 96.98 63.12 55040 247.84 247.84 55041 369.30 369.30 55060 275.15 275.15 55100 170.87 118.75 55110 280.01 280.01 55120 257.12 257.12 55150 352.66 352.66 55175 262.90 262.90 55180 502.18 502.18 55200 423.76 214.00 55250 S 376.71 174.91 55300 139.42 139.42 55400 N.C. N.C. 55450 S 302.49 190.66 55500 275.80 275.80 55520 289.16 289.16 55530 259.60 259.60 55535 311.51 311.51 55540 349.68 349.68 55550 308.95 308.95 55559 REPORT REPORT REPORT 55600 311.24 311.24 55605 364.77 364.77 55650 525.32 525.32 55680 265.19 265.19 55700 184.71 100.26 55705 199.14 199.14 55706 297.83 297.83 55720 346.54 346.54 55725 425.71 425.71 55801 791.93 791.93 55810 961.17 961.17 55812 1169.76 1169.76 55815 1291.84 1291.84 55821 637.56 637.56 55831 690.80 690.80

CODE NOTE NFAC FAC 26 TC

55840 979.19 979.19 55842 1048.75 1048.75 55845 1198.70 1198.70 55860 641.00 641.00 55862 811.86 811.86 55865 973.87 973.87 55866 1273.47 1273.47 55870 N.C. N.C. 55873 842.51 842.51 55875 559.10 559.10 55876 112.38 81.99 55899 REPORT REPORT REPORT 55920 316.17 316.17 55970 N.C. N.C. 55980 P 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

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CODE NOTE NFAC FAC 26 TC

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 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 50.26 28.52 57155 348.98 189.50 57156 158.63 107.44 57160 75.85 46.13 57170 68.40 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

CODE NOTE NFAC FAC 26 TC

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 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

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CODE NOTE NFAC FAC 26 TC

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 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 1128.80 214.13 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 808.73 808.73 58542 H 893.09 893.09 58543 H 907.89 907.89 58544 H 981.21 981.21

CODE NOTE NFAC FAC 26 TC

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 58555 229.29 184.92 58558 300.73 260.43 58559 334.68 334.68 58560 379.67 379.67 58561 536.38 536.38 58562 320.47 284.22 58563 1837.43 335.15 58565 S 1958.43 433.60 58570 H 867.64 867.64 58571 H 948.49 948.49 58572 H 1075.90 1075.90 58573 H 1210.66 1210.66 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 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

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CODE NOTE NFAC FAC 26 TC

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 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 37.47 32.34

59025 45.87 45.87 30.45 15.42

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

CODE NOTE NFAC FAC 26 TC

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 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 138.52 125.08 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 857.29 857.29 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 108.34 99.11 60100 81.93 56.92

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CODE NOTE NFAC FAC 26 TC

60200 445.44 445.44 60210 473.13 473.13 60212 677.63 677.63 60220 518.15 518.15 60225 623.57 623.57 60240 662.19 662.19 60252 889.63 889.63 60254 1153.54 1153.54 60260 745.02 745.02 60270 932.89 932.89 60271 719.12 719.12 60280 301.53 301.53 60281 402.92 402.92 60300 75.66 35.45 60500 683.26 683.26 60502 860.69 860.69 60505 945.70 945.70 60512 167.12 167.12 60520 713.40 713.40 60521 817.02 817.02 60522 983.04 983.04 60540 729.63 729.63 60545 835.50 835.50 60600 P 977.16 977.16 60605 1224.64 1224.64 60650 816.07 816.07 60659 REPORT REPORT REPORT 60699 REPORT REPORT REPORT 61000 102.96 102.96 61001 100.21 100.21 61020 124.60 124.60 61026 124.68 124.68 61050 104.76 104.76 61055 133.63 133.63 61070 80.32 80.32 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

CODE NOTE NFAC FAC 26 TC

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 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 1589.69 1589.69 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

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CODE NOTE NFAC FAC 26 TC

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 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 817.99 817.99 61552 1161.99 1161.99 61556 1495.33 1495.33 61557 1563.97 1563.97 61558 1534.87 1534.87 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

CODE NOTE NFAC FAC 26 TC

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 61611 407.56 407.56 61612 1511.32 1511.32 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 560.74 560.74 61641 197.18 197.18 61642 394.35 394.35 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 1293.75 1293.75 61750 1290.39 1290.39 61751 1259.86 1259.86 61760 1386.22 1386.22

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CODE NOTE NFAC FAC 26 TC

61770 1371.28 1371.28 61781 256.99 256.99 61782 210.30 210.30 61783 256.99 256.99 61790 776.20 776.20 61791 999.29 999.29 61796 758.37 758.37 61797 206.30 206.30 61798 758.37 758.37 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 777.74 777.74 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

CODE NOTE NFAC FAC 26 TC

62165 1411.97 1411.97 62180 1455.60 1455.60 62190 811.80 811.80 62192 884.37 884.37 62194 341.71 341.71 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 98.14 98.14 44.96 53.18

62256 529.79 529.79 62258 1037.99 1037.99 62263 621.33 358.94 62264 379.67 214.48 62267 247.36 162.34 62268 372.45 257.88 62269 401.16 254.62 62270 149.59 72.93 62272 177.93 79.68 62273 158.29 103.92 62280 296.07 144.96 62281 272.65 136.60 62282 283.08 127.07 62284 216.46 85.93 62287 524.45 524.45 62290 314.84 161.89 62291 295.19 155.48 62292 475.13 475.13 62294 717.73 717.73 62302 264.29 132.73 62303 274.89 134.67 62304 260.47 130.47 62305 284.55 136.10 62310 207.46 93.79 62311 183.25 78.67 62318 221.74 95.97 62319 200.65 88.99 62350 376.75 376.75 62351 779.04 779.04 62355 282.35 282.35 62360 257.26 257.26

Maryland Medical Assistance FS-67

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

62361 372.97 372.97 62362 397.80 397.80 62365 313.66 313.66 62367 36.99 21.82 62368 52.98 34.67 62369 135.21 37.01 62370 141.09 49.61 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 295.62 295.62 63044 277.73 277.73 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

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 1344.04 1344.04 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

Maryland Medical Assistance FS-68

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Physicians’ Services Fee Schedule – 2016 2016

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 913.27 405.13 63615 1056.32 1056.32 63620 758.37 758.37 63621 237.22 237.22 63650 389.62 389.62 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 497.35 497.35 64400 101.96 58.38 64402 104.43 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

CODE NOTE NFAC FAC 26 TC

64418 127.93 66.95 64420 144.97 60.68 64421 208.49 82.46 64425 122.34 85.94 64430 149.84 80.45 64435 139.63 80.73 64445 129.22 74.31 64446 85.80 85.80 64447 66.55 66.55 64448 76.21 76.21 64449 87.27 87.27 64450 99.10 67.71 64455 50.72 38.66 64461 162.88 94.10 64462 91.71 59.09 64463 179.95 91.92 64479 264.56 114.00 64480 132.56 70.30 64483 256.85 100.76 64484 113.24 55.42 64486 134.03 68.44 64487 164.14 78.52 64488 164.58 84.86 64489 230.06 94.55 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 111.11 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 1043.65 392.93 64565 162.32 113.90 64566 138.74 31.19 64568 678.53 678.53

Maryland Medical Assistance FS-69

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

64569 669.36 669.36 64570 591.66 591.66 64575 268.35 268.35 64580 280.72 280.72 64581 742.51 742.51 64585 311.92 155.43 64590 303.16 173.16 64595 304.07 137.65 64600 385.11 197.41 64605 544.86 311.99 64610 670.50 449.30 64611 107.00 96.69 64612 146.34 125.46 64615 127.80 114.93 64616 127.56 112.25 64617 197.65 118.59 64620 253.16 154.50 64630 222.92 176.93 64632 81.97 69.77 64633 488.31 250.45 64634 224.66 74.56 64635 479.83 245.34 64636 202.19 64.78 64640 220.71 170.76 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 58.37 35.57 64653 66.55 44.56 64680 292.50 149.67 64681 377.67 207.11 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

CODE NOTE NFAC FAC 26 TC

64721 392.81 391.28 64722 302.15 302.15 64726 277.77 277.77 64727 178.25 178.25 64732 346.88 346.88 64734 391.88 391.88 64736 351.79 351.79 64738 440.81 440.81 64740 434.91 434.91 64742 439.84 439.84 64744 395.38 395.38 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 178.27 178.27 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 628.18 628.18 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

Maryland Medical Assistance FS-70

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

64837 367.38 367.38 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 637.10 637.10 64911 772.26 772.26 64999 REPORT REPORT REPORT 65091 410.56 410.56 65093 412.61 412.61 65101 471.40 471.40 65103 490.85 490.85 65105 539.02 539.02 65110 779.33 779.33 65112 926.23 926.23 65114 953.69 953.69 65125 315.35 192.58 65130 464.66 464.66 65135 472.74 472.74

CODE NOTE NFAC FAC 26 TC

65140 512.32 512.32 65150 393.71 393.71 65155 545.81 545.81 65175 419.09 419.09 65205 36.48 27.54 65210 44.61 33.30 65220 37.63 27.50 65222 48.96 36.15 65235 429.62 429.62 65260 595.02 595.02 65265 667.50 667.50 65270 184.76 92.25 65272 325.13 216.37 65273 234.39 234.39 65275 347.73 276.55 65280 410.41 410.41 65285 638.35 638.35 65286 463.11 309.87 65290 302.99 302.99 65400 423.51 366.93 65410 94.62 65.43 65420 345.11 236.12 65426 426.05 294.44 65430 73.77 65.73 65435 51.64 44.21 65436 239.90 228.89 65450 202.91 199.93 65600 246.26 206.07 65710 684.73 684.73 65730 758.75 758.75 65750 769.15 769.15 65755 764.56 764.56 65756 747.27 747.27 65757 REPORT REPORT REPORT 65760 603.00 603.00 65765 603.00 603.00 65767 625.00 625.00 65770 876.38 876.38 65771 N.C. N.C. 65772 283.66 248.80 65775 342.69 342.69 65778 1066.39 62.17 65779 960.49 241.47

Maryland Medical Assistance FS-71

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

65780 557.32 557.32 65781 831.34 831.34 65782 718.95 718.95 65785 1863.32 335.77 65800 97.54 82.64 65810 286.78 286.78 65815 419.03 291.90 65820 474.33 474.33 65850 528.36 528.36 65855 227.20 194.96 65860 201.99 168.18 65865 301.91 301.91 65870 368.18 368.18 65875 390.23 390.23 65880 411.15 411.15 65900 604.92 604.92 65920 486.27 486.27 65930 402.67 402.67 66020 124.76 83.58 66030 111.59 72.17 66130 458.15 359.01 66150 536.81 536.81 66155 534.50 534.50 66160 605.60 605.60 66170 732.62 732.62 66172 918.40 918.40 66174 817.71 817.71 66175 932.72 932.72 66179 768.27 927.53 66180 722.36 722.36 66183 882.71 882.71 66184 536.13 677.56 66185 457.96 457.96 66220 446.56 446.56 66225 573.77 573.77 66250 491.89 339.99 66500 225.84 225.84 66505 246.71 246.71 66600 503.01 503.01 66605 659.00 659.00 66625 269.24 269.24 66630 349.58 349.58 66635 352.72 352.72

CODE NOTE NFAC FAC 26 TC

66680 316.31 316.31 66682 384.64 384.64 66700 281.67 244.46 66710 277.51 242.96 66711 389.56 389.56 66720 294.14 262.58 66740 275.43 245.05 66761 284.67 253.13 66762 296.91 261.19 66770 328.89 295.54 66820 258.32 258.32 66821 203.32 190.23 66825 481.01 481.01 66830 438.48 438.48 66840 429.89 429.89 66850 487.78 487.78 66852 521.94 521.94 66920 466.30 466.30 66930 528.52 528.52 66940 481.22 481.22 66982 677.60 677.60 66983 463.41 463.41 66984 494.07 494.07 66985 488.20 488.20 66986 578.02 578.02 66990 57.62 57.62 66999 REPORT REPORT REPORT 67005 303.71 303.71 67010 350.90 350.90 67015 364.26 364.26 67025 460.36 386.79 67027 527.76 527.76 67028 136.47 110.55 67030 323.98 323.98 67031 252.31 226.88 67036 597.14 597.14 67039 767.42 767.42 67040 883.52 883.52 67041 804.62 804.62 67042 919.72 919.72 67043 966.45 966.45 67101 486.15 413.28 67105 448.39 411.76

Maryland Medical Assistance FS-72

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

67107 748.97 748.97 67108 994.22 994.22 67110 568.91 494.50 67113 1061.99 1061.99 67115 303.08 303.08 67120 417.17 340.95 67121 558.25 558.25 67141 323.81 297.91 67145 325.34 304.19 67208 370.73 354.94 67210 430.19 412.94 67218 867.12 867.12 67220 663.08 626.48 67221 199.12 138.67 67225 20.06 18.52 67227 379.83 351.53 67228 730.54 636.15 67229 700.66 700.66 67250 498.77 498.77 67255 532.66 532.66 67299 REPORT REPORT REPORT 67311 370.24 370.24 67312 440.16 440.16 67314 413.18 413.18 67316 494.88 494.88 67318 432.94 432.94 67320 206.35 206.35 67331 195.28 195.28 67332 212.61 212.61 67334 192.32 192.32 67335 95.17 95.17 67340 229.62 229.62 67343 403.50 403.50 67345 149.52 133.73 67346 127.66 127.66 67399 REPORT REPORT REPORT 67400 595.98 595.98 67405 505.72 505.72 67412 555.83 555.83 67413 554.72 554.72 67414 812.31 812.31 67415 66.78 66.78 67420 1040.18 1040.18

CODE NOTE NFAC FAC 26 TC

67430 794.73 794.73 67440 770.29 770.29 67445 884.11 884.11 67450 796.34 796.34 67500 55.67 48.22 67505 52.94 45.19 67515 55.77 50.41 67550 620.85 620.85 67560 628.21 628.21 67570 738.06 738.06 67599 REPORT REPORT REPORT 67700 190.04 75.41 67710 162.53 63.83 67715 169.69 71.59 67800 81.03 65.25 67801 103.53 84.17 67805 128.61 104.20 67808 226.30 226.30 67810 146.72 61.01 67820 34.37 34.67 67825 83.39 76.25 67830 186.55 90.40 67835 277.26 277.26 67840 193.49 104.14 67850 143.70 91.65 67875 120.09 64.58 67880 295.97 235.65 67882 360.92 302.49 67900 421.51 323.55 67901 415.09 360.01 67902 432.75 432.75 67903 413.70 319.29 67904 471.08 363.86 67906 324.10 324.10 67908 318.05 277.85 67909 356.04 280.10 67911 338.16 338.16 67912 640.28 328.78 67914 262.52 182.43 67915 237.63 162.30 67916 355.91 273.73 67917 386.96 302.10 67921 250.74 170.93

Maryland Medical Assistance FS-73

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

67922 230.97 157.80 67923 372.65 294.32 67924 389.18 283.48 67930 245.35 160.61 67935 394.08 285.71 67938 172.50 75.14 67950 383.95 299.10 67961 382.70 291.01 67966 485.53 398.28 67971 460.30 460.30 67973 596.46 596.46 67974 594.11 594.11 67975 434.75 434.75 67999 REPORT REPORT REPORT 68020 75.39 69.73 68040 41.92 33.88 68100 119.19 64.89 68110 153.97 97.40 68115 215.93 120.99 68130 359.20 258.84 68135 99.39 95.21 68200 27.27 21.91 68320 471.76 328.82 68325 409.74 409.74 68326 397.67 397.67 68328 448.62 448.62 68330 397.30 282.96 68335 398.20 398.20 68340 360.65 244.52 68360 346.95 252.54 68362 403.35 403.35 68371 266.59 266.59 68399 REPORT REPORT REPORT 68400 198.47 93.82 68420 221.11 117.70 68440 75.09 62.00 68500 612.33 612.33 68505 615.12 615.12 68510 307.35 189.51 68520 430.78 430.78 68525 169.45 169.45 68530 301.29 173.27 68540 577.13 577.13

CODE NOTE NFAC FAC 26 TC

68550 704.78 704.78 68700 371.11 371.11 68705 161.60 109.06 68720 474.56 474.56 68745 476.32 476.32 68750 490.82 490.82 68760 137.06 92.73 68761 97.12 74.20 68770 343.67 343.67 68801 80.76 68.54 68810 173.32 148.02 68811 130.45 130.45 68815 303.39 169.90 68816 458.59 153.67 68840 79.42 68.99 68850 44.68 39.92 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 112.55 48.52 69205 90.87 90.87 69209 11.27 11.27 69210 43.91 28.75 69220 121.92 55.22 69222 197.32 124.17 69300 P 415.28 415.20 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 69433 175.09 114.84

Maryland Medical Assistance FS-74

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

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 REPORT REPORT REPORT 69711 P 763.65 763.65

CODE NOTE NFAC FAC 26 TC

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 214.80 324.56 69805 931.32 931.32 69806 837.76 837.76 69820 767.85 767.85 69840 819.77 819.77 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 137.43 137.43 39.47 97.96

70015 103.48 103.48 44.06 59.42

70030 21.15 21.15 6.30 14.85

70100 23.52 23.52 6.57 16.95

70110 29.94 29.94 8.86 21.08

70120 26.46 26.46 6.58 19.88

70130 40.81 40.81 12.30 28.51

70134 36.34 36.34 12.30 24.04

70140 24.67 24.67 6.86 17.81

70150 33.48 33.48 9.15 24.33

70160 24.12 24.12 6.30 17.82

70170 20.00 20.00 8.40 11.60

70190 27.63 27.63 7.44 20.19

70200 34.64 34.64 10.01 24.63

70210 24.09 24.09 6.00 18.09

70220 31.71 31.71 8.86 22.85

70240 21.71 21.71 6.86 14.85

70250 27.88 27.88 8.29 19.59

Maryland Medical Assistance FS-75

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

70260 38.70 38.70 12.29 26.41

70300 11.42 11.42 4.01 7.41

70310 24.14 24.14 6.01 18.13

70320 35.93 35.93 8.02 27.91

70328 22.93 22.93 6.58 16.35

70330 36.19 36.19 8.58 27.61

70332 73.45 73.45 19.46 53.99

70336 296.13 296.13 53.51 242.62

70350 16.67 16.67 6.29 10.38

70355 20.48 20.48 7.44 13.04

70360 20.56 20.56 6.30 14.26

70370 55.69 55.69 11.15 44.54

70371 82.84 82.84 30.02 52.82

70380 28.86 28.86 6.30 22.56

70390 76.39 76.39 13.73 62.66

70450 177.00 177.00 30.90 146.10

70460 225.04 225.04 41.20 183.84

70470 273.25 273.25 46.07 227.18

70480 196.11 196.11 46.34 149.77

70481 266.69 266.69 50.08 216.61

70482 306.40 306.40 52.36 254.04

70486 190.63 190.63 40.91 149.72

70487 257.57 257.57 47.24 210.33

70488 305.23 305.23 51.22 254.01

70490 196.06 196.06 46.64 149.42

70491 255.34 255.34 50.07 205.27

70492 306.38 306.38 52.36 254.02

70496 319.95 319.95 63.54 256.41

70498 320.24 320.24 63.82 256.42

70540 316.79 316.79 48.63 268.16

70542 368.69 368.69 58.66 310.03

70543 507.50 507.50 80.74 426.76

70544 311.47 311.47 43.48 267.99

70545 353.06 353.06 43.50 309.56

70546 475.29 475.29 65.26 410.03

70547 311.17 311.17 43.19 267.98

70548 353.37 353.37 43.50 309.87

70549 475.29 475.29 65.26 410.03

70551 321.14 321.14 53.50 267.64

70552 374.45 374.45 64.67 309.78

70553 494.58 494.58 85.27 409.31

70554 537.50 537.50 75.79 461.71

70555 13.34 13.34 13.34

CODE NOTE NFAC FAC 26 TC

70557 205.36 205.36 57.50 147.86

70558 227.07 227.07 63.58 163.49

70559 228.04 228.04 63.85 164.19

71010 19.65 19.65 6.58 13.07

71015 23.19 23.19 7.44 15.75

71020 25.53 25.53 7.73 17.80

71021 31.38 31.38 9.73 21.65

71022 34.90 34.90 10.86 24.04

71023 47.61 47.61 13.75 33.86

71030 36.11 36.11 10.87 25.24

71034 69.45 69.45 17.48 51.97

71035 25.60 25.60 6.57 19.03

71100 25.53 25.53 7.73 17.80

71101 30.81 30.81 9.73 21.08

71110 32.87 32.87 9.73 23.14

71111 40.53 40.53 11.15 29.38

71120 26.73 26.73 7.44 19.29

71130 29.40 29.40 7.73 21.67

71250 194.07 194.07 42.35 151.72

71260 260.85 260.85 44.63 216.22

71270 303.99 303.99 50.07 253.92

71275 326.65 326.65 69.84 256.81

71550 320.76 320.76 52.64 268.12

71551 372.39 372.39 62.38 310.01

71552 511.92 511.92 85.18 426.74

71555 375.66 375.66 65.82 309.84

72020 18.61 18.61 5.47 13.14

72040 28.20 28.20 7.72 20.48

72050 40.25 40.25 10.87 29.38

72052 50.58 50.58 13.16 37.42

72070 27.01 27.01 7.72 19.29

72072 30.27 30.27 7.72 22.55

72074 35.91 35.91 7.72 28.19

72080 27.91 27.91 7.73 20.18

72081 33.58 33.58 11.38 22.20

72082 54.10 54.10 13.77 40.33

72083 58.70 58.70 14.93 43.77

72084 69.82 69.82 17.31 52.51

72100 29.69 29.69 7.72 21.97

72110 41.44 41.44 10.87 30.57

72114 53.86 53.86 13.16 40.70

72120 37.40 37.40 7.72 29.68

72125 191.44 191.44 41.77 149.67

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CODE NOTE NFAC FAC 26 TC

72126 260.00 260.00 43.78 216.22

72127 299.99 299.99 46.05 253.94

72128 191.44 191.44 41.77 149.67

72129 260.28 260.28 44.09 216.19

72130 299.99 299.99 46.05 253.94

72131 191.44 191.44 41.77 149.67

72132 260.00 260.00 43.78 216.22

72133 299.99 299.99 46.05 253.94

72141 325.68 325.68 57.81 267.87

72142 379.31 379.31 69.53 309.78

72146 325.65 325.65 57.80 267.85

72147 379.25 379.25 69.52 309.73

72148 321.37 321.37 53.51 267.86

72149 374.45 374.45 64.67 309.78

72156 502.01 502.01 92.72 409.29

72157 501.98 501.98 92.72 409.26

72158 494.58 494.58 85.27 409.31

72159 476.58 476.58 476.58 72170 21.15 21.15 6.30 14.85

72190 30.01 30.01 7.44 22.57

72191 322.64 322.64 65.82 256.82

72192 189.14 189.14 39.49 149.65

72193 258.55 258.55 42.07 216.48

72194 297.74 297.74 43.77 253.97

72195 320.73 320.73 52.63 268.10

72196 372.64 372.64 62.68 309.96

72197 511.60 511.60 84.93 426.67

72198 375.06 375.06 65.22 309.84

72200 22.64 22.64 6.30 16.34

72202 27.33 27.33 6.86 20.47

72220 23.80 23.80 6.30 17.50

72240 143.87 143.87 32.62 111.25

72255 132.00 132.00 32.01 99.99

72265 130.03 130.03 29.75 100.28

72270 200.88 200.88 48.07 152.81

72275 86.36 86.36 25.98 60.38

72285 158.15 158.15 32.99 125.16

72295 139.70 139.70 23.76 115.94

73000 21.47 21.47 5.72 15.75

73010 22.34 22.34 6.30 16.04

73020 18.80 18.80 5.43 13.37

73030 23.78 23.78 6.57 17.21

73040 85.06 85.06 19.75 65.31

CODE NOTE NFAC FAC 26 TC

73050 28.22 28.22 7.44 20.78

73060 23.50 23.50 6.30 17.20

73070 21.19 21.19 5.44 15.75

73080 26.19 26.19 6.30 19.89

73085 79.12 79.12 19.76 59.36

73090 21.47 21.47 5.72 15.75

73092 21.47 21.47 5.72 15.75

73100 21.76 21.76 5.72 16.04

73110 25.32 25.32 6.30 19.02

73115 77.65 77.65 19.45 58.20

73120 21.17 21.17 5.72 15.45

73130 23.84 23.84 6.30 17.54

73140 20.91 20.91 4.57 16.34

73200 189.21 189.21 39.49 149.72

73201 250.31 250.31 41.78 208.53

73202 297.79 297.79 43.78 254.01

73206 322.61 322.61 65.84 256.77

73218 316.79 316.79 48.63 268.16

73219 368.69 368.69 58.66 310.03

73220 487.61 487.61 77.82 409.79

73221 316.77 316.77 48.62 268.15

73222 368.66 368.66 58.65 310.01

73223 507.48 507.48 80.74 426.74

73225 454.14 454.14 127.16 73501 25.92 25.92 8.08 17.84

73502 35.83 35.83 9.56 26.27

73503 44.81 44.81 12.29 32.52

73521 34.58 34.58 9.87 24.71

73522 42.27 42.27 12.87 29.40

73523 49.10 49.10 13.77 35.33

73525 79.09 79.09 19.73 59.36

73551 24.08 24.08 7.19 16.89

73552 28.10 28.10 8.08 20.02

73560 22.34 22.34 6.30 16.04

73562 26.17 26.17 6.58 19.59

73564 29.69 29.69 7.72 21.97

73565 22.94 22.94 6.30 16.64

73580 98.12 98.12 19.73 78.39

73590 21.75 21.75 6.30 15.45

73592 21.47 21.47 5.72 15.75

73600 21.17 21.17 5.72 15.45

73610 23.84 23.84 6.30 17.54

73615 81.48 81.48 19.73 61.75

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CODE NOTE NFAC FAC 26 TC

73620 20.87 20.87 5.72 15.15

73630 23.84 23.84 6.30 17.54

73650 20.57 20.57 5.72 14.85

73660 20.33 20.33 4.57 15.76

73700 189.21 189.21 39.49 149.72

73701 251.49 251.49 42.07 209.42

73702 298.09 298.09 44.09 254.00

73706 326.08 326.08 69.29 256.79

73718 316.79 316.79 48.63 268.16

73719 368.69 368.69 58.66 310.03

73720 487.32 487.32 77.53 409.79

73721 316.77 316.77 48.62 268.15

73722 368.66 368.66 58.65 310.01

73723 507.79 507.79 81.04 426.75

73725 375.65 375.65 65.81 309.84

74000 20.84 20.84 6.58 14.26

74010 28.49 28.49 8.30 20.19

74020 30.81 30.81 9.73 21.08

74022 36.68 36.68 11.46 25.22

74150 194.07 194.07 43.55 150.52

74160 262.90 262.90 46.35 216.55

74170 304.68 304.68 50.67 254.01

74174 486.67 486.67 88.28 398.39

74175 325.51 325.51 68.68 256.83

74176 181.41 181.41 69.17 74177 286.56 286.56 72.50 74178 363.20 363.20 80.30 74181 320.98 320.98 52.93 268.05

74182 372.68 372.68 62.68 310.00

74183 511.60 511.60 84.93 426.67

74185 375.06 375.06 65.22 309.84

74190 65.00 65.00 23.47 41.53

74210 57.13 57.13 13.16 43.97

74220 63.83 63.83 16.89 46.94

74230 66.99 66.99 19.17 47.82

74235 51.00 51.00 21.42 29.58

74240 79.85 79.85 25.19 54.66

74241 84.01 84.01 24.88 59.13

74245 126.21 126.21 32.92 93.29

74246 90.53 90.53 25.19 65.34

74247 93.80 93.80 25.19 68.61

74249 135.12 135.12 32.92 102.20

74250 72.75 72.75 16.89 55.86

CODE NOTE NFAC FAC 26 TC

74251 135.88 135.88 25.19 110.69

74260 87.05 87.05 18.03 69.02

74261 234.05 234.05 83.06 151.01

74262 320.87 320.87 91.16 229.71

74263 REPORT REPORT REPORT 0.00

74270 94.11 94.11 25.19 68.92

74280 140.97 140.97 35.48 105.49

74283 141.26 141.26 72.66 68.60

74290 45.62 45.62 11.46 34.16

74300 30.00 30.00 12.60 17.40

74301 12.50 12.50 10.17 2.33

74328 111.50 111.50 35.23 76.27

74329 111.50 111.50 35.23 76.27

74330 140.50 140.50 44.61 95.89

74340 58.00 58.00 24.36 33.64

74355 53.37 53.37 22.42 30.95

74360 58.00 58.00 27.82 30.18

74363 30.00 30.00 12.60 17.40

74400 81.89 81.89 17.75 64.14

74410 87.25 87.25 17.75 69.50

74415 98.85 98.85 17.74 81.11

74420 26.00 26.00 10.92 15.08

74425 26.00 26.00 10.92 15.08

74430 56.60 56.60 11.73 44.87

74440 61.58 61.58 13.73 47.85

74445 40.00 40.00 16.80 23.20

74450 20.00 20.00 8.40 11.60

74455 69.33 69.33 12.31 57.02

74470 20.00 20.00 8.40 11.60

74485 102.55 102.55 20.04 82.51

74710 37.50 37.50 12.29 25.21

74712 366.27 366.27 128.12 238.15

74713 199.61 199.61 75.85 123.76

74740 59.49 59.49 13.74 45.75

74742 26.00 26.00 26.00 74775 56.00 56.00 23.52 32.48

75557 356.61 356.61 89.15 267.46

75559 381.75 381.75 113.91 267.84

75561 507.89 507.89 98.63 409.26

75563 528.43 528.43 118.58 409.85

75565 69.07 69.07 9.27 59.80

75571 54.78 54.78 20.64 34.14

75572 197.32 197.32 62.71 134.61

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CODE NOTE NFAC FAC 26 TC

75573 280.22 280.22 89.64 190.58

75574 289.13 289.13 85.44 203.69

75600 292.91 292.91 17.75 275.16

75605 231.53 231.53 67.14 164.39

75625 231.96 231.96 33.26 198.70

75630 269.20 269.20 55.24 213.96

75635 344.49 344.49 87.88 256.61

75658 257.69 257.69 40.87 216.82

75705 304.73 304.73 72.80 231.93

75710 251.37 251.37 35.39 215.98

75716 290.92 290.92 43.70 247.22

75726 249.60 249.60 34.62 214.98

75731 253.19 253.19 35.98 217.21

75733 291.53 291.53 44.87 246.66

75736 248.43 248.43 34.90 213.53

75741 235.59 235.59 38.33 197.26

75743 263.22 263.22 51.22 212.00

75746 241.47 241.47 33.88 207.59

75756 260.94 260.94 37.86 223.08

75774 172.39 172.39 9.10 163.29

75791 202.53 202.53 67.48 135.03

75801 70.50 70.50 29.61 40.89

75803 50.50 50.50 21.21 29.29

75805 70.50 70.50 29.61 40.89

75807 43.50 43.50 18.27 25.23

75809 59.38 59.38 16.58 42.80

75810 41.50 41.50 17.43 24.07

75820 82.25 82.25 26.07 56.18

75822 104.31 104.31 38.34 65.97

75825 221.97 221.97 32.25 189.72

75827 224.53 224.53 31.97 192.56

75831 232.26 232.26 33.14 199.12

75833 259.87 259.87 45.92 213.95

75840 227.84 227.84 32.79 195.05

75842 260.61 260.61 45.76 214.85

75860 229.34 229.34 33.35 195.99

75870 226.37 226.37 32.33 194.04

75872 304.13 304.13 44.34 259.79

75880 85.52 85.52 25.77 59.75

75885 241.57 241.57 42.23 199.34

75887 243.34 243.34 42.75 200.59

75889 226.00 226.00 32.45 193.55

75891 226.37 226.37 32.53 193.84

CODE NOTE NFAC FAC 26 TC

75893 192.58 192.58 14.33 178.25

75894 50.00 50.00 50.00 75898 100.00 100.00 50.00 50.00

75901 119.71 119.71 17.74 101.97

75902 79.06 79.06 14.02 65.04

75952 121.41 121.41 50.99 70.42

75953 50.00 50.00 21.00 29.00

75954 60.14 60.14 25.26 34.88

75956 194.56 194.56 81.72 112.84

75957 166.80 166.80 70.06 96.74

75958 111.06 111.06 46.65 64.41

75959 97.29 97.29 40.86 56.43

75962 229.82 229.82 14.06 215.76

75964 143.32 143.32 10.49 132.83

75966 274.98 274.98 37.56 237.42

75968 140.31 140.31 10.47 129.84

75970 189.00 189.00 41.49 147.51

75978 230.19 230.19 13.86 216.33

75984 88.40 88.40 25.75 62.65

75989 122.15 122.15 43.22 78.93

76000 67.81 67.81 5.99 61.82

76001 48.00 48.00 24.00 24.00

76010 22.03 22.03 6.58 15.45

76080 50.33 50.33 19.75 30.58

76098 16.40 16.40 5.72 10.68

76100 78.85 78.85 21.17 57.68

76101 122.89 122.89 20.88 102.01

76102 153.81 153.81 20.58 133.23

76120 57.12 57.12 13.74 43.38

76125 16.50 16.50 6.93 9.57

76140 10.00 10.00 10.00 76376 77.68 77.68 7.42 70.26

76377 100.01 100.01 28.23 71.78

76380 118.63 118.63 36.66 81.97

76390 364.73 364.73 364.73 76496 REPORT REPORT REPORT 76497 REPORT REPORT REPORT 76498 REPORT REPORT REPORT 76499 REPORT REPORT REPORT 76506 71.29 71.29 23.74 47.55

76510 117.08 117.08 57.35 59.73

76511 82.49 82.49 34.96 47.53

76512 77.11 77.11 34.98 42.13

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CODE NOTE NFAC FAC 26 TC

76513 69.45 69.45 24.65 44.80

76514 9.27 9.27 6.60 2.67

76516 54.79 54.79 20.07 34.72

76519 58.06 58.06 20.36 37.70

76529 54.43 54.43 21.21 33.22

76536 80.34 80.34 19.73 60.61

76604 65.50 65.50 19.75 45.75

76641 92.82 92.82 30.35 62.47

76642 76.07 76.07 28.27 47.80

76700 102.56 102.56 29.19 73.37

76705 76.71 76.71 21.46 55.25

76770 98.79 98.79 26.61 72.18

76775 77.33 77.33 21.17 56.16

76776 107.09 107.09 27.47 79.62

76800 92.29 92.29 38.83 53.46

76801 101.98 101.98 35.18 66.80

76802 59.63 59.63 30.05 29.58

76805 110.01 110.01 35.18 74.83

76810 76.82 76.82 34.90 41.92

76811 170.09 170.09 68.07 102.02

76812 111.01 111.01 63.78 47.23

76813 100.47 100.47 42.64 57.83

76814 64.11 64.11 34.56 29.55

76815 70.37 70.37 23.16 47.21

76816 78.16 78.16 30.61 47.55

76817 74.14 74.14 26.59 47.55

76818 96.84 96.84 39.33 57.51

76819 78.35 78.35 28.90 49.45

76820 49.76 49.76 17.60 32.16

76821 77.68 77.68 25.46 52.22

76825 134.68 134.68 59.78 74.90

76826 77.03 77.03 29.46 47.57

76827 62.98 62.98 20.59 42.39

76828 46.09 46.09 20.32 25.77

76830 88.15 88.15 24.88 63.27

76831 88.41 88.41 25.45 62.96

76856 88.45 88.45 24.89 63.56

76857 61.30 61.30 13.74 47.56

76870 87.34 87.34 23.18 64.16

76872 100.35 100.35 25.47 74.88

76873 131.14 131.14 56.35 74.79

76881 97.11 97.11 23.63 76882 25.10 25.10 16.39

CODE NOTE NFAC FAC 26 TC

76885 73.85 73.85 26.31 47.54

76886 70.14 70.14 22.60 47.54

76930 77.18 77.18 25.83 51.35

76932 37.00 37.00 35.72 1.28

76936 203.09 203.09 57.98 145.11

76937 27.36 27.36 11.15 16.21

76940 66.48 66.48 33.24 33.24

76941 125.00 125.00 52.50 72.50

76942 136.73 136.73 24.32 112.41

76945 17.53 17.53 7.36 10.17

76946 40.45 40.45 12.37 28.08

76948 41.23 41.23 12.41 28.82

76965 125.77 125.77 41.03 84.74

76970 59.17 59.17 14.01 45.16

76975 40.00 40.00 20.00 20.00

76977 11.35 11.35 1.33 10.02

76998 8.22 8.22 8.22 76999 REPORT REPORT REPORT 77001 74.34 74.34 13.46 60.88

77002 56.27 56.27 18.86 37.41

77003 50.81 50.81 20.25 30.56

77011 474.28 474.28 43.49 430.79

77012 175.07 175.07 35.85 139.22

77013 23.34 23.34 23.34 77014 141.71 141.71 30.61 111.10

77021 374.14 374.14 54.92 319.22

77022 25.33 25.33 25.33 77051 11.51 11.51 2.29 9.22

77052 11.51 11.51 2.29 9.22

77053 72.77 72.77 13.16 59.61

77054 98.77 98.77 16.30 82.47

77055 63.49 63.49 25.47 38.02

77056 80.18 80.18 31.46 48.72

77057 63.76 63.76 25.47 38.29

77058 661.32 661.32 58.92 602.40

77059 663.63 663.63 51.30 612.33

77061 48.19 48.19 25.68 22.51

77062 48.19 48.19 25.68 22.51

77063 48.18 48.18 25.67 22.51

77071 26.14 26.14 26.14 77072 18.15 18.15 6.86 11.29

77073 31.68 31.68 10.03 21.65

77074 52.24 52.24 16.60 35.64

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CODE NOTE NFAC FAC 26 TC

77075 74.71 74.71 19.75 54.96

77076 59.65 59.65 25.17 34.48

77077 37.56 37.56 11.16 26.40

77078 65.61 65.61 8.86 56.75

77080 64.08 64.08 7.73 56.35

77081 26.40 26.40 7.72 18.68

77084 299.87 299.87 57.22 242.65

77085 48.75 48.75 12.82 35.93

77086 30.91 30.91 7.47 23.44

77261 53.07 53.07 53.07 77262 80.16 80.16 80.16 77263 119.19 119.19 119.19 77280 144.87 144.87 25.45 119.42

77285 243.33 243.33 37.47 205.86

77290 355.05 355.05 55.78 299.27

77293 354.53 354.53 81.54 272.99

77295 602.65 602.65 139.03 463.62

77299 REPORT REPORT REPORT 77300 61.26 61.26 23.24 38.02

77301 1561.27 1561.27 286.81 1274.46

77306 122.95 122.95 58.92 64.03

77307 239.45 239.45 122.34 117.11

77316 158.57 158.57 59.26 99.31

77317 207.67 207.67 78.06 129.61

77318 298.82 298.82 123.02 175.80

77321 114.02 114.02 33.09 80.93

77331 48.86 48.86 32.46 16.40

77332 64.47 64.47 20.24 44.23

77333 63.07 63.07 29.14 33.93

77334 137.36 137.36 46.17 91.19

77336 56.74 56.74 56.74 77338 428.28 428.28 199.28 229.00

77370 106.68 106.68 106.68 77371 982.06 982.06 982.06 77372 702.25 702.25 702.25 77373 1309.95 1309.95 1309.95 77385 REPORT REPORT REPORT 77386 REPORT REPORT REPORT 77387 REPORT REPORT REPORT 77399 REPORT REPORT REPORT 77401 27.64 27.64 27.64 77402 94.21 94.21 94.21 77407 120.70 120.70 120.70

CODE NOTE NFAC FAC 26 TC

77412 139.45 139.45 139.45 77417 16.05 16.05 16.05 77422 108.77 108.77 108.77 77423 148.38 148.38 148.38 77424 N.C. N.C. 77425 N.C. N.C. 77427 133.02 133.02 133.02 77431 71.95 71.95 71.95 77432 301.91 301.91 301.91 77435 492.57 492.57 492.57 77469 249.94 249.94 77470 214.76 214.76 58.44 156.32

77499 REPORT REPORT REPORT 77520 REPORT REPORT REPORT 77522 REPORT REPORT REPORT 77523 REPORT REPORT REPORT 77525 REPORT REPORT REPORT 77600 250.84 250.84 55.76 195.08

77605 407.98 407.98 74.25 333.73

77610 365.49 365.49 53.69 311.80

77615 517.35 517.35 74.34 443.01

77620 258.40 258.40 57.96 200.44

77750 242.70 242.70 177.32 65.38

77761 252.01 252.01 134.90 117.11

77762 350.61 350.61 205.91 144.70

77763 493.72 493.72 308.28 185.44

77767 196.08 196.08 46.02 150.06

77768 307.59 307.59 60.93 246.66

77770 278.96 278.96 84.83 194.13

77771 519.35 519.35 165.78 353.57

77772 793.10 793.10 235.07 558.03

77778 613.65 613.65 411.76 201.89

77789 72.73 72.73 41.19 31.54

77790 62.14 62.14 37.46 24.68

77799 REPORT REPORT REPORT 78012 72.10 72.10 7.68 64.42

78013 145.67 145.67 14.76 130.91

78014 210.79 210.79 19.92 191.71

78015 142.91 142.91 24.32 118.59

78016 209.34 209.34 29.48 179.86

78018 234.09 234.09 31.49 202.60

78020 68.88 68.88 21.76 47.12

78070 144.22 144.22 29.75 114.47

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CODE NOTE NFAC FAC 26 TC

78071 313.40 313.40 47.17 266.23

78072 65.36 65.36 65.36 78075 284.91 284.91 26.61 258.30

78099 REPORT REPORT REPORT 78102 113.05 113.05 19.75 93.30

78103 156.44 156.44 27.19 129.25

78104 184.29 184.29 28.92 155.37

78110 53.81 53.81 7.16 46.65

78111 81.04 81.04 8.02 73.02

78120 67.38 67.38 8.30 59.08

78121 90.14 90.14 11.46 78.68

78122 121.00 121.00 16.32 104.68

78130 117.68 117.68 22.32 95.36

78135 228.83 228.83 23.18 205.65

78140 127.39 127.39 22.32 105.07

78185 128.72 128.72 14.60 114.12

78190 182.95 182.95 38.84 144.11

78191 191.08 191.08 22.32 168.76

78195 233.70 233.70 43.77 189.93

78199 REPORT REPORT REPORT 78201 121.23 121.23 15.72 105.51

78202 142.25 142.25 18.31 123.94

78205 197.35 197.35 25.75 171.60

78206 249.14 249.14 34.90 214.24

78215 134.84 134.84 17.74 117.10

78216 116.80 116.80 20.32 96.48

78226 285.26 285.26 29.30 255.96

78227 291.19 291.19 35.20 255.99

78230 112.27 112.27 16.30 95.97

78231 109.73 109.73 18.59 91.14

78232 113.67 113.67 16.89 96.78

78258 152.04 152.04 26.91 125.13

78261 178.18 178.18 25.19 152.99

78262 179.39 179.39 24.31 155.08

78264 198.61 198.61 28.34 170.27

78265 330.32 330.32 40.86 289.46

78266 427.93 427.93 45.36 382.57

78267 8.51 8.51 8.51 78268 72.87 72.87 72.87 78270 61.17 61.17 7.44 53.73

78271 61.78 61.78 7.15 54.63

78272 77.42 77.42 9.43 67.99

78278 224.19 224.19 35.78 188.41

CODE NOTE NFAC FAC 26 TC

78282 25.00 25.00 12.50 12.50

78290 198.25 198.25 24.90 173.35

78291 169.08 169.08 31.77 137.31

78299 REPORT REPORT REPORT 78300 123.32 123.32 22.60 100.72

78305 167.31 167.31 30.05 137.26

78306 187.16 187.16 31.48 155.68

78315 226.20 226.20 36.92 189.28

78320 209.08 209.08 37.78 171.30

78350 28.11 28.11 28.11 78351 N.C. N.C. 78399 REPORT REPORT REPORT 78414 56.00 56.00 23.11 32.89

78428 140.09 140.09 29.83 110.26

78445 112.86 112.86 17.74 95.12

78451 177.17 177.17 52.25 124.92

78452 303.24 303.24 61.80 241.44

78453 154.45 154.45 37.93 116.52

78454 148.23 148.23 50.26 97.97

78456 192.61 192.61 36.65 155.96

78457 136.81 136.81 27.46 109.35

78458 161.22 161.22 32.63 128.59

78459 759.04 759.04 76.81 682.23

78466 132.75 132.75 25.78 106.97

78468 171.84 171.84 30.40 141.44

78469 207.84 207.84 35.00 172.84

78472 210.69 210.69 36.39 174.30

78473 296.13 296.13 55.32 240.81

78481 191.68 191.68 37.90 153.78

78483 276.81 276.81 57.44 219.37

78491 231.74 231.74 64.89 166.85

78492 496.30 496.30 99.66 396.64

78494 243.73 243.73 45.31 198.42

78496 86.59 86.59 11.52 75.07

78499 REPORT REPORT REPORT 78579 151.50 151.50 19.35 132.15

78580 155.56 155.56 26.91 128.65

78582 279.03 279.03 41.74 237.26

78597 170.27 170.27 28.62 141.65

78598 262.17 262.17 32.61 229.56

78599 REPORT REPORT REPORT 78600 125.97 125.97 16.02 109.95

78601 151.41 151.41 18.31 133.10

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CODE NOTE NFAC FAC 26 TC

78605 144.54 144.54 19.47 125.07

78606 210.44 210.44 22.87 187.57

78607 274.26 274.26 44.35 229.91

78608 55.00 55.00 15.40 42.90

78609 53.49 53.49 53.49 78610 136.69 136.69 11.48 125.21

78630 232.61 232.61 24.61 208.00

78635 192.14 192.14 22.33 169.81

78645 180.86 180.86 20.31 160.55

78647 251.88 251.88 32.32 219.56

78650 222.63 222.63 22.33 200.30

78660 114.86 114.86 19.17 95.69

78699 REPORT REPORT REPORT 78700 129.49 129.49 16.60 112.89

78701 153.54 153.54 17.75 135.79

78707 184.61 184.61 34.91 149.70

78708 162.52 162.52 44.08 118.44

78709 248.88 248.88 50.95 197.93

78710 195.95 195.95 23.75 172.20

78725 76.69 76.69 13.74 62.95

78730 59.49 59.49 6.91 52.58

78740 136.83 136.83 20.59 116.24

78761 149.65 149.65 25.75 123.90

78799 REPORT REPORT REPORT 78800 141.36 141.36 24.03 117.33

78801 184.27 184.27 29.19 155.08

78802 238.84 238.84 31.19 207.65

78803 268.80 268.80 39.78 229.02

78804 427.34 427.34 38.63 388.71

78805 141.27 141.27 26.33 114.94

78806 256.92 256.92 31.19 225.73

78807 268.23 268.23 39.51 228.72

78808 34.12 34.12 34.12 78811 600.00 600.00 78.24 521.76

78812 900.00 900.00 96.66 803.34

78813 1100.00 1100.00 100.21 999.79

78814 850.00 850.00 109.57 740.44

78815 1150.00 1150.00 121.33 1028.68

78816 1350.00 1350.00 124.07 1225.94

78999 REPORT REPORT REPORT 79005 126.64 126.64 64.64 62.00

79101 136.25 136.25 71.86 64.39

79200 138.29 138.29 71.81 66.48

CODE NOTE NFAC FAC 26 TC

79300 43.85 43.85 21.93 21.93

79403 182.87 182.87 83.04 99.83

79440 132.66 132.66 72.43 60.23

79445 91.38 91.38 45.69 45.69

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 90371 116.40 116.40 116.40 90375 153.81 153.81 90376 142.76 142.76 90378 INVOICE INVOICE REPORT 90384 38.75 38.75 90385 25.43 25.43 90386 INVOICE INVOICE REPORT 90389 114.00 114.00 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 110.22 110.22 90586 110.64 110.64 90620 160.75 160.75 90621 115.75 115.75 90625 N.C. N.C.

90630 18.49 90632 44.06 44.06 90633 21.17 21.17 90634 23.91 23.91 90636 78.16 78.16 90644 INVOICE INVOICE REPORT

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CODE NOTE NFAC FAC 26 TC

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 N.C. N.C. 90654 N.C. N.C. 90655 15.45 15.45 90656 12.54 12.54 90657 5.68 5.68 5.68 90658 11.37 11.37 11.37 90660 22.32 22.32 90661 INVOICE INVOICE REPORT 90662 INVOICE INVOICE REPORT 90664 N.C. N.C. 90666 INVOICE INVOICE REPORT 90667 INVOICE INVOICE REPORT 90668 INVOICE INVOICE REPORT 90670 95.48 95.48 90672 24.60 24.60 90673 INVOICE INVOICE REPORT 90675 176.58 176.58 90676 146.00 146.00 90680 63.25 63.25 90681 63.25 63.25 90685 23.23 23.23 90686 19.41 19.41 90687 9.13 90688 16.81 16.81 90690 7.00 7.00 90691 58.94 58.94 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 47.00 47.01 47.01 90710 117.50 117.50 90713 28.01 28.01 90714 20.12 20.12 90715 33.17 33.17 90716 81.75 81.75 81.75 90717 59.49 59.49 90723 60.06 60.06 60.06

CODE NOTE NFAC FAC 26 TC

90732 37.61 37.61 90733 100.43 100.43 100.43 90734 82.00 82.00 90736 INVOICE INVOICE REPORT 90738 INVOICE INVOICE REPORT 90739 N.C. N.C. 90740 119.42 119.42 90743 24.22 24.22 24.22 90744 24.22 24.22 24.22 90746 59.71 59.71 90747 119.42 119.42 90748 45.32 45.32 90749 INVOICE INVOICE REPORT 90785 N.C. N.C. 90791 146.63 146.63 90792 154.19 154.19 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 90863 N.C. N.C. 90865 115.98 100.79 115.98 90867 REPORT REPORT REPORT 90868 REPORT REPORT REPORT 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

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CODE NOTE NFAC FAC 26 TC

90901 28.53 14.87 28.53 90911 70.23 33.95 70.23 90935 49.15 49.15 90937 80.32 80.32 90940 15.00 15.00 90945 51.45 51.45 90947 82.03 82.03 90951 538.34 538.34 90952 473.88 473.88 90953 370.66 370.66 90954 374.13 374.13 90955 308.01 308.01 90956 241.59 241.59 90957 329.23 329.23 90958 270.78 270.78 90959 210.28 210.28 90960 207.32 207.32 90961 169.83 169.83 90962 132.65 132.65 90963 419.33 419.33 90964 297.28 297.28 90965 257.97 257.97 90966 161.50 161.50 90967 14.98 14.98 90968 8.89 8.89 90969 10.32 10.32 90970 5.75 5.75 90989 N.C. N.C. 90993 N.C. N.C. 90997 64.62 64.62 90999 REPORT REPORT REPORT 91010 154.68 154.68 47.29 91013 19.39 19.39 8.09 91020 178.52 178.52 54.15 91022 151.42 151.42 54.44 91030 103.74 103.74 34.69 91034 167.00 167.00 36.96 91035 373.37 373.37 59.93 91037 122.63 122.63 37.27 91038 105.77 105.77 42.43 91040 308.14 308.14 34.88 91065 47.61 47.61 7.44 91110 732.83 732.83 136.82

CODE NOTE NFAC FAC 26 TC

91111 587.22 587.22 39.05 548.17

91112 1031.58 1031.58 93.87 91117 117.58 117.58 91120 323.05 323.05 35.18 91122 189.84 189.84 65.80 91132 13.46 13.46 91133 16.96 16.96 91200 31.28 31.28 12.53 18.75

91299 REPORT REPORT REPORT 92002 50.56 32.49 92004 94.76 64.68 92012 53.47 32.32 92014 77.48 49.78 92015 28.32 13.70 28.32 92018 92.58 92.58 92.58 92019 46.96 46.96 92020 18.22 13.75 18.22 92025 23.90 23.90 12.60 11.30

92060 40.36 40.36 25.50 92065 P 30.41 30.41 13.16 92071 31.59 28.03 92072 100.79 80.01 92081 37.87 37.87 13.17 92082 49.38 49.38 16.04 92083 56.74 56.74 18.34 92100 61.81 34.29 61.81 92132 30.41 30.41 17.38 92133 37.09 37.09 24.05 92134 37.09 37.09 24.05 92136 61.64 61.64 92140 40.68 18.79 40.68 92145 13.43 13.43 7.48 5.95

92225 16.44 13.75 16.44 92226 15.01 12.33 15.01 92227 9.85 9.85 92228 24.96 24.96 14.24 92230 48.27 22.03 48.27 92235 94.93 94.93 30.41 92240 149.92 149.92 41.59 92250 53.55 53.55 16.04 92260 12.50 8.06 12.50 92265 58.63 58.63 28.88 92270 63.71 63.71 29.20

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CODE NOTE NFAC FAC 26 TC

92275 91.41 91.41 37.55 92283 31.89 31.89 6.30 92284 51.16 51.16 92285 30.13 30.13 92286 93.71 93.71 24.36 92287 84.31 30.42 84.31 92310 P 65.21 42.57 92311 P 65.35 39.00 92312 P 72.85 46.49 92313 P 60.33 33.67 92314 48.44 24.72 48.44 92315 P 43.72 16.37 43.72 92316 P 55.29 26.27 55.29 92317 44.91 16.07 92325 P 18.75 18.75 92326 P 36.82 36.82 92340 26.55 13.38 92341 29.71 16.67 92342 31.99 19.36 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 22.45 11.43 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 26.63 92508 30.47 13.69 30.47 92511 149.65 54.91 149.65 92512 58.49 24.76 58.49 92516 59.85 20.81 92520 47.75 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 24.76 80.85 92531 3.50 3.50 3.50 92532 3.50 3.50 3.50 92533 3.50 3.50 3.50

CODE NOTE NFAC FAC 26 TC

92534 3.50 3.50 3.50 92537 34.43 34.43 26.90 7.53

92538 17.54 17.54 13.45 4.09

92540 87.06 87.06 71.45 15.61

92541 48.51 48.51 16.63 92542 48.30 48.30 13.13 92544 39.61 39.61 10.66 92545 37.10 37.10 9.59 92546 82.40 82.40 13.48 92547 4.97 4.97 4.97 92548 95.38 95.38 23.87 92550 18.83 18.83 92551 7.73 7.73 7.73 92552 18.35 18.35 18.35 92553 27.53 27.53 27.53 92555 16.02 16.02 16.02 92556 22.61 22.61 22.61 92557 46.80 44.14 46.80 92558 N.C. N.C. 92559 N.C. N.C. 92560 5.50 5.50 5.50 92561 29.06 29.06 29.06 92562 17.18 17.18 17.18 92563 16.02 16.02 16.02 92564 19.60 19.60 19.60 92565 13.22 13.22 13.22 92567 16.15 13.21 16.15 92568 16.02 16.02 16.02 92570 31.92 30.03 92571 16.41 16.41 92572 10.40 10.40 92575 22.31 22.31 92576 18.66 18.66 92577 17.70 17.70 92579 35.25 33.46 35.25 92582 30.25 30.25 92583 33.57 33.57 33.57 92584 70.26 70.26 70.26 92585 100.70 100.70 23.67 92586 64.54 64.54 92587 39.90 39.90 5.32 92588 65.10 65.10 16.22 92590 13.00 13.00 13.00

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CODE NOTE NFAC FAC 26 TC

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 25.52 25.52 25.52 92597 97.60 42.36 97.60 92601 138.69 135.49 92602 94.88 79.41 92603 107.52 100.67 92604 64.53 59.17 92605 REPORT REPORT REPORT 92606 REPORT REPORT REPORT 92607 121.74 121.74 92608 22.95 22.95 92609 63.08 63.08 92610 81.43 72.41 92611 88.58 88.58 92612 149.99 62.07 92613 28.70 28.40 92614 134.84 62.07 92615 25.24 25.24 92616 186.01 92.02 92617 31.56 31.56 92618 N.C. N.C. 92620 47.54 47.54 47.54 92621 11.81 11.81 11.81 92625 47.25 47.25 47.25 92626 64.22 64.22 64.22 92627 15.45 15.45 15.45 92630 N.C. N.C. 92633 N.C. N.C. 92640 42.93 42.93 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

CODE NOTE NFAC FAC 26 TC

92938 N.C. N.C. 92941 574.80 574.80 92943 574.80 574.80 92944 N.C. N.C. 92950 212.81 133.24 212.81 92953 8.62 8.62 8.62 92960 216.81 100.82 216.81 92961 189.35 189.35 189.35 92970 129.14 129.14 92971 74.54 74.54 92973 133.20 133.20 92974 122.03 122.03 92975 293.08 293.08 293.08 92977 100.24 100.24 100.24 92978 98.00 98.00 97.79 92979 61.00 61.00 61.00 92986 1010.69 1010.69 92987 1047.28 1047.28 92990 798.42 798.42 92992 293.39 293.39 293.39 92993 297.00 297.00 297.00 92997 464.10 464.10 464.10 92998 233.87 233.87 93000 17.58 17.58 17.58 93005 11.28 11.28 11.28 93010 6.30 6.30 6.30 93015 80.32 80.32 80.32 93016 17.80 17.80 17.80 93017 51.03 51.03 51.03 93018 11.96 11.96 11.96 93024 91.37 91.37 45.35 93025 194.37 194.37 29.58 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 7.48 7.83

93224 103.88 103.88 103.88 93225 30.59 30.59 30.59 93226 44.95 44.95 44.95 93227 20.38 20.38 20.38 93228 19.19 19.19 93229 REPORT REPORT REPORT 93260 56.07 56.07 37.63 18.44

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CODE NOTE NFAC FAC 26 TC

93261 51.30 51.30 32.86 18.44

93268 217.68 217.68 217.68 93270 16.60 16.60 16.60 93271 N.C. N.C. 93272 20.29 20.29 20.29 93278 37.27 37.27 9.46 93279 42.51 42.51 27.14 15.37

93280 50.17 50.17 32.58 17.59

93281 58.66 58.66 37.99 20.67

93282 54.27 54.27 35.55 18.71

93283 66.03 66.03 44.81 93284 77.23 77.23 53.21 24.02

93285 36.81 36.81 22.28 14.54

93286 20.87 20.87 11.37 9.50

93287 27.39 27.39 16.48 10.91

93288 32.99 32.99 18.18 14.81

93289 50.43 50.43 32.83 17.60

93290 24.36 24.36 15.97 8.18

93291 31.61 31.61 18.48 13.13

93292 28.53 28.53 18.18 10.35

93293 46.01 46.01 12.74 33.27

93294 27.70 27.70 93295 49.96 49.96 93296 28.17 28.17 93297 19.19 19.19 93298 22.28 22.28 93299 REPORT REPORT REPORT 93303 171.05 171.05 48.15 122.90

93304 102.34 102.34 27.81 74.53

93306 205.69 205.69 53.99 151.70

93307 148.36 148.36 35.59 112.77

93308 88.34 88.34 20.66 67.68

93312 243.16 243.16 83.14 160.02

93313 30.44 30.44 30.44 93314 210.92 210.92 47.31 163.61

93315 72.04 72.04 24.73 47.31

93316 32.53 32.53 32.53 93317 47.18 47.18 10.66 36.52

93318 56.00 56.00 28.00 93320 65.66 65.66 14.65 51.01

93321 31.39 31.39 5.79 25.60

93325 38.56 38.56 1.80 36.76

93350 152.18 152.18 57.71 94.47

CODE NOTE NFAC FAC 26 TC

93351 212.36 212.36 93352 29.64 29.64 93355 190.44 190.44 190.44 93451 646.25 646.25 116.33 529.93

93452 715.24 715.24 207.42 507.82

93453 935.91 935.91 271.41 664.50

93454 737.74 737.74 206.57 531.17

93455 860.78 860.78 241.02 619.76

93456 933.94 933.94 270.84 663.10

93457 1051.49 1051.49 294.42 757.07

93458 890.17 890.17 249.25 640.92

93459 982.82 982.82 285.02 697.80

93460 1051.49 1051.49 315.45 736.04

93461 1205.26 1205.26 349.53 855.73

93462 168.42 168.42 93463 89.16 89.16 93464 212.10 212.10 93503 81.01 81.01 81.01 93505 487.44 487.44 175.92 93530 331.00 331.00 109.23 93531 827.00 827.00 305.99 93532 855.00 855.00 324.90 93533 754.00 754.00 366.44 93561 69.00 69.00 23.84 93562 16.00 16.00 7.41 93563 45.96 45.96 93564 46.81 46.81 93565 35.37 35.37 93566 142.68 35.38 93567 117.32 39.82 93568 128.76 36.31 93571 97.00 97.00 96.98 93572 89.00 89.00 75.73 93580 731.27 731.27 93581 965.98 965.98 93582 560.13 560.13 93583 623.39 623.39 93600 57.87 57.87 28.94 93602 57.84 57.84 28.92 93603 57.82 57.82 24.28 93609 149.00 149.00 74.50 93610 81.98 81.98 40.99 93612 81.95 81.95 40.98

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CODE NOTE NFAC FAC 26 TC

93613 283.62 283.62 283.62 93615 25.00 25.00 25.00 93616 45.45 45.45 45.45 93618 116.21 116.21 58.11 93619 320.00 320.00 320.00 93620 320.58 320.58 320.58 93621 100.00 100.00 100.00 93622 300.00 300.00 170.28 93623 77.59 77.59 77.59 93624 129.81 129.81 129.81 93631 204.79 204.79 204.79 93640 176.00 176.00 176.00 93641 175.00 175.00 175.00 93642 276.39 276.39 269.62 93644 267.70 267.70 175.53 92.17

93650 433.48 433.48 433.48 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 73.80 93662 113.00 113.00 56.50 93668 12.49 12.49 93701 29.12 29.12 6.44 93702 100.25 100.25 100.25 93724 267.68 267.68 188.85 93740 8.11 8.11 8.11 93745 22.07 22.07 93750 N.C. N.C. 93770 6.24 6.24 6.24 93784 53.92 53.92 93786 25.89 25.89 93788 12.91 12.91 93790 13.45 13.45 93797 14.60 7.47 14.60 93798 21.58 11.36 21.58 93799 REPORT REPORT REPORT 93880 140.16 140.16 22.02 93882 130.93 130.93 14.86 93886 152.77 152.77 34.62 93888 70.66 70.66 23.16 93890 111.97 111.97 37.21

CODE NOTE NFAC FAC 26 TC

93892 116.55 116.55 41.77 93893 116.55 116.55 41.77 93895 N.C. N.C. 93922 96.77 96.77 9.14 93923 148.12 148.12 16.57 131.55

93924 180.45 180.45 93925 139.09 139.09 21.16 93926 89.12 89.12 14.29 93930 134.97 134.97 17.15 93931 86.23 86.23 11.43 93965 99.03 99.03 12.58 93970 143.23 143.23 25.15 93971 91.34 91.34 16.59 93975 184.79 184.79 66.64 93976 161.85 161.85 43.78 93978 142.38 142.38 24.32 93979 91.09 91.09 16.31 93980 136.91 136.91 46.06 93981 105.44 105.44 16.03 93982 31.43 31.43 93990 84.27 84.27 9.43 93998 N.C. N.C. 94002 61.99 61.99 94003 45.33 45.33 94004 32.79 32.79 94005 N.C. N.C. 94010 26.21 26.21 6.00 94011 75.84 75.84 94012 116.54 116.54 94013 24.61 24.61 94014 37.03 37.03 37.03 94015 19.05 19.05 19.05 94016 18.00 18.00 18.00 94060 45.02 45.02 10.28 34.74

94070 45.39 45.39 20.55 94150 16.25 16.25 16.25 94200 17.65 17.65 3.99 94250 20.66 20.66 3.99 94375 28.11 28.11 10.28 94400 40.38 40.38 13.98 94450 38.40 38.40 94452 42.68 42.68 10.55 94453 58.64 58.64 13.71

Maryland Medical Assistance FS-89

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CODE NOTE NFAC FAC 26 TC

94610 46.19 46.19 94620 67.55 67.55 94621 119.84 119.84 50.02 94640 10.69 10.69 94642 24.70 24.70 24.70 94644 29.15 29.15 94645 10.98 10.98 94660 41.76 26.27 41.76 94662 25.99 25.99 25.99 94664 11.84 11.84 11.84 94667 17.19 17.19 94668 N.C. N.C. 94669 29.40 29.40 94680 51.93 51.93 8.85 94681 61.48 61.48 6.79 94690 48.36 48.36 2.57 94726 46.50 46.50 10.23 36.27

94727 36.38 36.38 10.22 26.16

94728 36.38 36.38 10.22 26.16

94729 46.34 46.34 6.83 39.51

94750 53.20 53.20 7.71 94760 2.14 2.14 94761 4.55 4.55 94762 21.75 21.75 94770 24.78 24.78 94772 171.00 171.00 94774 REPORT REPORT REPORT 94775 REPORT REPORT REPORT 94776 REPORT REPORT REPORT 94777 30.00 30.00 94780 43.41 19.66 94781 16.93 6.83 94799 20.00 20.00 95004 4.44 4.44 4.44 95012 14.90 14.90 95017 7.61 3.16 95018 18.75 7.80 95024 5.32 5.32 5.32 95027 4.31 4.31 95028 8.32 8.32 8.32 95044 5.88 5.88 5.88 95052 6.50 6.50 6.50 95056 21.43 21.43 21.43

CODE NOTE NFAC FAC 26 TC

95060 16.64 16.64 16.64 95065 13.68 13.68 13.68 95070 41.27 41.27 95071 55.00 55.00 95076 99.38 59.93 95079 69.34 55.10 95115 10.20 10.20 10.20 95117 12.67 12.67 12.67 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 95134 6.50 6.50 6.50 95144 8.90 2.38 8.90 95145 11.93 2.38 11.93 95146 18.36 2.38 18.36 95147 17.77 2.38 17.77 95148 24.91 2.38 24.91 95149 32.95 2.38 32.95 95165 8.55 2.38 8.55 95170 6.75 2.38 6.75 95180 110.50 79.49 110.50 95199 REPORT REPORT REPORT 95250 113.43 113.43 113.43 95251 28.25 28.25 28.25 95782 907.45 907.45 106.63 800.82

95783 968.56 968.56 116.61 851.95

95800 173.25 173.25 95801 80.78 80.78 95803 REPORT REPORT REPORT 95805 420.39 420.39 66.59 95806 160.52 160.52 58.59 95807 414.95 414.95 57.39 95808 512.35 512.35 93.45 95810 628.08 628.08 123.17 95811 690.50 690.50 132.30 95812 179.56 179.56 39.79 95813 220.30 220.30 62.94 157.36

95816 164.98 164.98 39.79 95819 167.06 167.06 39.78 127.28

95822 182.81 182.81 39.80 Maryland Medical Assistance FS-90

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CODE NOTE NFAC FAC 26 TC

95824 25.00 25.00 95827 244.15 244.15 38.60 95829 998.78 998.78 95830 138.59 64.94 138.59 95831 20.13 11.05 20.13 95832 18.31 11.45 18.31 95833 28.20 18.20 28.20 95834 33.06 23.58 33.06 95851 13.45 6.26 13.45 95852 10.55 4.47 10.55 95857 31.38 20.27 31.38 95860 64.35 64.35 36.39 95861 87.55 87.55 57.87 95863 104.93 104.93 69.30 95864 126.72 126.72 73.90 95865 84.28 84.28 95866 64.50 64.50 95867 52.67 52.67 29.21 95868 72.33 72.33 43.82 95869 31.27 31.27 14.03 95870 30.68 30.68 14.04 95872 117.85 117.85 96.19 95873 30.98 30.98 14.34 95874 30.38 30.38 14.33 95875 73.91 73.91 41.55 95885 48.08 48.08 14.80 33.28

95886 47.67 47.67 25.29 22.38

95887 66.68 66.68 31.03 35.65

95905 66.20 66.20 2.46 63.74

95907 80.77 80.77 43.29 37.48

95908 99.61 99.61 54.43 45.18

95909 119.38 119.38 64.93 54.45

95910 157.09 157.09 86.89 70.20

95911 157.09 157.09 89.70 67.39

95912 222.43 222.43 130.19 92.24

95913 257.66 257.66 154.36 103.30

95921 51.95 51.95 32.03 95922 61.36 61.36 35.19 95923 87.96 87.96 33.20 95924 125.77 125.77 72.62 53.15

95925 78.88 78.88 20.32 95926 77.70 77.70 20.03 95927 80.37 80.37 20.91

CODE NOTE NFAC FAC 26 TC

95928 143.36 143.36 54.98 95929 151.11 151.11 55.28 95930 82.53 82.53 13.17 95933 49.33 49.33 22.04 95937 41.51 41.51 25.16 95938 256.54 256.54 36.48 220.06

95939 399.89 399.89 96.09 303.80

95940 26.85 26.85 95941 N.C. N.C. 95943 REPORT REPORT REPORT 95950 183.77 183.77 55.54 95951 244.00 244.00 41.33 202.64

95953 320.17 320.17 119.87 200.30

95954 194.28 194.28 86.28 95955 106.91 106.91 36.03 95956 565.28 565.28 113.06 452.22

95957 180.58 180.58 72.99 107.59

95958 266.59 266.59 155.42 95961 173.90 173.90 120.13 95962 163.70 163.70 123.02 95965 210.26 210.26 210.26 95966 104.33 104.33 104.33 95967 86.17 86.17 86.17 95970 38.02 16.65 38.02 95971 40.18 27.38 40.18 95972 76.29 54.85 76.29 95974 125.67 109.89 125.67 95975 69.78 63.53 69.78 95978 148.47 126.44 148.47 95979 66.66 60.11 66.66 95980 29.14 29.14 95981 21.00 11.47 95982 31.47 22.83 95990 48.14 48.14 95991 67.01 26.99 67.01 95992 REPORT REPORT REPORT 95999 20.00 20.00 96000 62.21 62.21 62.21 96001 74.26 74.26 74.26 96002 14.58 14.58 14.58 96003 12.84 12.84 12.84 96004 79.62 79.62 79.62 96020 16.48 16.48 8.24

Maryland Medical Assistance FS-91

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CODE NOTE NFAC FAC 26 TC

96040 29.47 29.47 96101 95.72 95.30 95.72 96102 28.10 28.10 96103 N.C. N.C. 96105 58.30 58.30 58.30 96110 8.86 8.86 8.86 96111 95.52 93.74 95.52 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 96150 26.91 26.45 96151 25.29 24.83 96152 5.50 5.41 96153 N.C. N.C. 96154 N.C. N.C. 96155 N.C. N.C. 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 123.79 123.79 96370 12.18 12.18 96371 55.67 55.67 96372 15.83 15.83 96373 14.02 14.02 96374 44.95 44.95 96375 19.74 19.74 96376 10.90 10.90 96379 REPORT REPORT REPORT 96401 50.32 50.32 50.32 96402 31.57 31.57 31.57 96405 87.31 21.83 87.31 96406 119.14 31.05 119.14 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

CODE NOTE NFAC FAC 26 TC

96417 61.84 61.84 61.84 96420 87.47 87.47 87.47 96422 145.25 145.25 145.25 96423 62.56 62.56 62.56 96425 142.56 142.56 142.56 96440 267.39 100.46 267.39 96446 150.17 17.71 96450 212.31 75.14 212.31 96521 109.80 109.80 109.80 96522 87.45 87.45 87.45 96523 21.36 21.36 21.36 96542 136.18 36.63 136.18 96549 REPORT REPORT REPORT 96567 85.99 85.99 96570 41.76 41.76 96571 20.03 20.03 96900 15.45 15.45 15.45 96902 15.52 14.89 15.52 96904 56.86 56.86 96910 45.80 45.80 45.80 96912 58.58 58.58 58.58 96913 79.34 79.34 79.34 96920 120.15 47.60 96921 118.32 47.86 96922 174.17 81.22 96931 REPORT REPORT REPORT 96932 REPORT REPORT REPORT 96933 REPORT REPORT REPORT 96934 REPORT REPORT REPORT 96935 REPORT REPORT REPORT 96936 REPORT REPORT REPORT 96999 REPORT REPORT REPORT 97001 72.06 72.06 72.06 97002 28.36 28.36 97003 76.65 76.65 76.65 97004 34.08 34.08 34.08 97005 N.C. N.C. 97006 N.C. N.C. 97010 3.63 3.63 3.63 97012 10.65 10.65 10.65 97014 10.15 10.15 10.15 97016 11.04 11.04 11.04 97018 5.79 5.79 5.79

Maryland Medical Assistance FS-92

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CODE NOTE NFAC FAC 26 TC

97022 12.55 12.55 12.55 97024 3.93 3.93 3.93 97026 3.63 3.63 3.63 97028 4.83 4.83 4.83 97032 11.84 11.84 11.84 97033 17.48 17.48 17.48 97034 10.41 10.41 10.41 97035 8.67 8.67 8.67 97036 18.64 18.64 18.64 97039 REPORT REPORT REPORT 97110 29.03 29.03 29.03 97112 21.39 21.39 21.39 97113 24.97 24.97 24.97 97116 17.89 17.89 17.89 97124 16.47 16.47 16.47 97139 9.88 9.88 9.88 97140 19.04 19.04 97150 18.25 18.25 18.25 97530 30.56 30.56 30.56 97532 17.52 17.52 97533 18.73 18.73 97535 21.98 21.98 97537 19.60 19.60 97542 N.C. N.C. 97545 10.50 10.50 97546 N.C. N.C. 97597 41.98 25.13 97598 25.68 12.06 97602 N.C. N.C. 97605 25.11 19.95 97606 27.10 22.02 97607 REPORT REPORT REPORT 97608 REPORT REPORT REPORT 97610 REPORT REPORT REPORT 97750 21.37 21.37 21.37 97755 24.41 24.41 97760 N.C. N.C. 97761 N.C. N.C. 97762 N.C. N.C. 97799 20.00 20.00 97802 30.03 30.03 97803 26.35 26.35 97804 N.C. N.C.

CODE NOTE NFAC FAC 26 TC

97810 25.32 21.15 97811 19.20 17.71 97813 26.74 22.87 97814 21.52 19.44 98925 20.77 15.71 20.77 98926 28.53 23.17 28.53 98927 36.85 30.29 36.85 98928 43.16 35.71 43.16 98929 49.47 40.83 49.47 98940 18.12 15.14 18.12 98941 24.98 21.42 24.98 98942 32.69 29.11 32.69 98943 16.40 14.02 16.40 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.

Maryland Medical Assistance FS-93

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

99140 N.C. N.C. 99143 30.00 30.00 99144 27.93 27.93 99145 7.49 7.49 99148 29.63 29.63 99149 27.93 27.93 99150 7.49 7.49 99170 99.27 62.94 99172 4.50 4.50 99173 2.16 2.16 99174 N.C. N.C. 99175 26.54 26.54 26.54 99177 3.50 3.50 99183 149.52 85.32 149.52 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 45.22 45.22 45.22 99199 REPORT REPORT REPORT 99201 43.41 26.07 99202 73.84 49.27 99203 106.80 75.37 99204 162.35 127.30 99205 203.38 165.45 99211 19.82 8.98 99212 43.03 24.60 99213 71.91 49.86 99214 105.75 76.48 99215 142.34 108.36 99217 71.21 71.21 71.21 99218 97.27 97.27 99219 132.20 132.20 99220 180.61 180.61 99221 99.19 99.19 99.19 99222 133.70 133.70 133.70 99223 197.73 197.73 197.73 99224 38.78 38.78 99225 70.94 70.94 99226 102.44 102.44 99231 38.42 38.42 38.42 99232 70.22 70.22 70.22

CODE NOTE NFAC FAC 26 TC

99233 101.39 101.39 101.39 99234 130.54 130.54 130.54 99235 164.74 164.74 164.74 99236 212.07 212.07 212.07 99238 70.82 70.82 70.82 99239 104.83 104.83 104.83 99241 46.97 31.79 46.97 99242 88.02 66.70 88.02 99243 120.39 93.29 120.39 99244 179.59 149.96 179.59 99245 218.71 185.47 218.71 99251 47.59 47.59 47.59 99252 72.84 72.84 72.84 99253 111.90 111.90 111.90 99254 162.70 162.70 162.70 99255 196.16 196.16 196.16 99281 20.69 20.69 20.69 99282 40.35 40.35 40.35 99283 60.30 60.30 60.30 99284 114.36 114.36 114.36 99285 168.77 168.77 168.77 99288 7.50 7.50 7.50 99291 270.16 218.13 270.16 99292 120.07 109.23 120.07 99304 89.54 89.54 99305 127.30 127.30 99306 162.18 162.18 99307 43.82 43.82 99308 67.86 67.86 99309 89.37 89.37 99310 132.75 132.75 99315 71.54 71.54 71.54 99316 103.41 103.41 103.41 99318 93.70 93.70 99324 54.10 54.10 99325 78.60 78.60 99326 135.71 135.71 99327 181.16 181.16 99328 211.54 211.54 99334 59.02 59.02 99335 92.95 92.95 99336 131.40 131.40 99337 188.15 188.15

Maryland Medical Assistance FS-94

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Physicians’ Services Fee Schedule – 2016 2016

CODE NOTE NFAC FAC 26 TC

99339 N.C. N.C. 99340 N.C. N.C. 99341 53.74 53.74 53.74 99342 77.15 77.15 77.15 99343 126.56 126.56 126.56 99344 177.77 177.77 177.77 99345 215.59 215.59 215.59 99347 54.13 54.13 54.13 99348 82.14 82.14 82.14 99349 125.21 125.21 125.21 99350 173.68 173.68 173.68 99354 97.95 90.72 97.95 99355 95.03 87.80 95.03 99356 89.73 89.73 89.73 99357 89.00 89.00 89.00 99358 N.C. N.C. 99359 N.C. N.C. 99360 N.C. N.C. 99363 N.C. N.C. 99364 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 108.61 74.64 108.61 99382 113.43 79.46 113.43 99383 118.27 84.66 118.27 99384 133.49 99.53 133.49 99385 128.96 95.37 128.96 99386 149.73 116.12 149.73 99387 162.35 124.77 162.35 99391 97.70 68.07 97.70 99392 104.28 74.64 104.28 99393 103.91 74.64 103.91 99394 113.93 84.66 113.93 99395 116.34 87.07 116.34 99396 123.95 94.69 123.95 99397 133.49 99.53 133.49

CODE NOTE NFAC FAC 26 TC

99401 N.C. N.C. 99402 N.C. N.C. 99403 N.C. N.C. 99404 N.C. N.C. 99406 13.92 12.12 99407 27.08 25.27 99408 34.30 32.49 99409 66.79 64.99 99411 N.C. N.C. 99412 N.C. N.C. 99415 9.06 9.06 99416 5.09 5.09 99420 N.C. N.C. 99429 REPORT REPORT REPORT 99441 N.C. N.C. 99442 N.C. N.C. 99443 N.C. N.C. 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 93.94 93.94 99461 90.38 61.47 99462 40.73 40.73 99463 116.61 116.61 99464 69.64 69.64 99465 149.13 149.13 99466 224.14 224.14 99467 113.39 113.39 99468 919.57 919.57 99469 388.09 388.09 99471 860.01 860.01 99472 399.93 399.93 99475 562.88 562.88 99476 338.78 338.78 99477 348.68 348.68 99478 133.28 133.28 99479 121.54 121.54 99480 116.34 116.34

Maryland Medical Assistance FS-95

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CODE NOTE NFAC FAC 26 TC

99485 74.64 74.64 99486 64.99 64.99 99487 N.C. N.C. 99489 N.C. N.C. 99490 N.C. N.C. 99495 162.16 107.59 99496 228.33 155.70 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. G0202 103.38 103.38 27.22 76.16 G0204 116.81 116.81 32.40 G0453 26.20 26.20 G0455 112.28 52.40 S8032 REPORT REPORT REPORT REPORT

CODE NOTE NFAC FAC 26 TC

Maryland Medical Assistance FS-96

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Maryland Medical Assistance FS-97