nd medicaid professional fee schedule-7-1-19 (updated-2)...1' 0(',&$,'...

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULE as of 07/01/2019 Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof. CODE MODIFIER MEDICAID FEE 10004 $52.06 10005 $127.27 10006 $60.02 10007 $289.25 10008 $162.70 10009 $475.09 10010 $285.99 10021 $98.34 10030 $584.28 10035 $491.72 10036 $424.83 10040 $109.55 10060 $119.68 10061 $207.17 10080 $186.20 10081 $277.68 10120 $154.02 10121 $274.42 10140 $169.21 10160 $131.25 10180 $249.11 11000 $56.04 11001 $22.06 11004 $570.54 11005 $765.06 11006 $696.00 11008 $269.00 11010 $487.38 11011 $535.47 11012 $693.47 11042 $122.93 11043 $231.04 11044 $312.39 11045 $41.22 11046 $72.67 11047 $121.85 11055 $57.13 11056 $68.33 11057 $75.57 11102 $99.79 11103 $53.87 11104 $125.46 11105 $61.46 11106 $151.85 1 of 238

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Page 1: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE10004 $52.0610005 $127.2710006 $60.0210007 $289.2510008 $162.7010009 $475.0910010 $285.9910021 $98.3410030 $584.2810035 $491.7210036 $424.8310040 $109.5510060 $119.6810061 $207.1710080 $186.2010081 $277.6810120 $154.0210121 $274.4210140 $169.2110160 $131.2510180 $249.1111000 $56.0411001 $22.0611004 $570.5411005 $765.0611006 $696.0011008 $269.0011010 $487.3811011 $535.4711012 $693.4711042 $122.9311043 $231.0411044 $312.3911045 $41.2211046 $72.6711047 $121.8511055 $57.1311056 $68.3311057 $75.5711102 $99.7911103 $53.8711104 $125.4611105 $61.4611106 $151.85

1 of 238

Page 2: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE11107 $72.6711200 $88.9411201 $18.8011300 $98.7111301 $120.7611302 $141.3711303 $155.8311305 $103.7711306 $122.9311307 $145.3511308 $154.3911310 $114.9811311 $137.0311312 $160.1711313 $187.6511400 $125.4611401 $152.2211402 $168.8511403 $194.5211404 $220.1911406 $314.5611420 $125.8211421 $159.0911422 $178.6111423 $203.2011424 $235.0111426 $334.4411440 $139.2011441 $171.0211442 $190.5411443 $225.9711444 $282.7411446 $390.8411450 $394.8211451 $496.0611462 $385.7811463 $503.2911470 $422.6611471 $517.0311600 $195.9611601 $230.6711602 $249.4811603 $284.5511604 $315.28

2 of 238

Page 3: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE11606 $449.7811620 $197.4111621 $231.4011622 $257.7911623 $301.1811624 $339.8611626 $407.4811640 $203.5611641 $239.7111642 $272.6111643 $319.9811644 $394.1011646 $511.9711719 $14.8211720 $33.6211721 $45.9211730 $110.2811732 $33.2611740 $52.4311750 $157.2811755 $124.0111760 $194.5211762 $289.9711765 $172.1011770 $283.4611771 $584.2811772 $699.6111900 $54.6011901 $68.7011920 $180.0611921 $206.0911922 $61.1011950 $68.7011951 $97.9811952 $132.6911954 $154.3911960 $967.8911970 $609.2311971 $479.4311976 $145.3511980 $95.0911981 $142.0911982 $157.2811983 $229.23

3 of 238

Page 4: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE12001 $89.6712002 $108.8312004 $127.2712005 $165.2312006 $194.5212007 $223.0812011 $109.5512013 $113.8912014 $136.6712015 $165.2312016 $207.9012017 $149.3212018 $169.2112020 $288.5212021 $167.0412031 $247.3112032 $306.6012034 $320.3412035 $385.4212036 $424.8312037 $479.0612041 $246.9412042 $297.2012044 $368.4312045 $404.9412046 $482.3212047 $528.9612051 $267.1912052 $302.2612053 $353.6012054 $369.5112055 $479.0612056 $563.6712057 $596.5713100 $342.0313101 $403.1413102 $121.4813120 $356.8613121 $433.5113122 $132.6913131 $391.9313132 $481.9613133 $177.1613151 $427.72

4 of 238

Page 5: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE13152 $510.1613153 $192.7113160 $795.0714000 $624.7714001 $797.9614020 $699.2514021 $870.9914040 $763.6114041 $940.0514060 $776.9914061 $1,011.2814301 $1,078.1714302 $218.3814350 $691.3015002 $348.9015003 $73.7615004 $400.9715005 $122.2115040 $257.0715050 $568.3715100 $857.6215101 $185.8415110 $794.3415111 $113.1715115 $793.9815116 $166.6815120 $850.0215121 $208.6215130 $664.1815131 $98.7115135 $860.5115136 $97.6215150 $686.9615151 $116.7815152 $143.5415155 $797.2415156 $157.2815157 $174.9915200 $835.2015201 $145.7115220 $775.9015221 $136.3115240 $937.5215241 $183.67

5 of 238

Page 6: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE15260 $1,015.9815261 $212.9615271 $146.0715272 $26.7615273 $305.1515274 $74.8415275 $155.1115276 $34.3515277 $333.7215278 $88.5815570 $910.7615572 $886.9015574 $905.7015576 $806.6415600 $330.4615610 $360.4715620 $442.9115630 $462.7915650 $511.9715730 $1,548.1915731 $1,121.5515733 $1,053.5815734 $1,494.6815736 $1,224.2415738 $1,303.7815740 $1,012.3615750 $916.9115756 $2,294.8115757 $2,272.3915758 $2,292.2815760 $852.9215770 $667.4415775 $307.3215776 $445.0815777 $215.4915780 $924.1415781 $553.9115782 $580.6615783 $481.6015786 $248.3915787 $45.5615788 $455.5615789 $554.2715792 $421.22

6 of 238

Page 7: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE15793 $496.0615819 $792.9015820 $574.5215821 $617.5415822 $452.3115823 $618.6315830 $1,168.1915832 $917.2715833 $870.2715834 $887.9915835 $933.5415836 $789.6415837 $865.9315838 $639.9615839 $882.9215840 $1,006.2215841 $1,778.1415842 $2,705.1815845 $1,018.5115850 $90.7515851 $101.6015852 $45.9215860 $106.3015920 $615.3715922 $784.5815931 $683.7115933 $848.9415934 $935.7115935 $1,091.9115936 $885.4615937 $1,030.8015940 $693.1115941 $904.2615944 $896.3015945 $988.5015946 $1,620.1415950 $598.3815951 $883.2915952 $904.9815953 $997.9015956 $1,153.0115958 $1,179.7616000 $70.5016020 $82.07

7 of 238

Page 8: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE16025 $149.6916030 $189.4616035 $195.6016036 $80.9917000 $65.4417003 $5.7817004 $152.5817106 $345.2917107 $446.1617108 $644.6617110 $111.7217111 $131.9717250 $82.4417260 $95.8117261 $145.7117262 $177.1617263 $193.4317264 $207.1717266 $235.0117270 $150.0517271 $165.2317272 $188.3717273 $209.7017274 $247.3117276 $285.6317280 $140.6517281 $179.6917282 $206.0917283 $246.2217284 $280.5717286 $359.0317311 $670.6917312 $398.8017313 $628.0317314 $381.0817315 $79.5417340 $52.4317360 $126.9119000 $111.0019001 $27.1219020 $474.0019030 $169.2119081 $659.8419082 $540.53

8 of 238

Page 9: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE19083 $646.4719084 $521.3719085 $984.8819086 $791.8119100 $151.1319101 $336.2519105 $2,895.7219110 $487.0219112 $460.2619120 $494.2519125 $545.9519126 $157.6419260 $1,172.8919271 $1,583.6219272 $1,722.4619281 $246.5819282 $172.8219283 $275.8719284 $210.0719285 $495.7019286 $429.1719287 $838.4519288 $672.8619294 $160.8919296 $4,077.2919297 $92.5619298 $1,007.6619300 $535.4719301 $642.1319302 $883.2919303 $941.8619304 $577.4119305 $1,114.3219306 $1,181.5719307 $1,179.0419316 $768.3119318 $1,096.6119324 $530.4119325 $643.5719328 $497.1419330 $632.3619340 $993.5619342 $923.7819350 $827.61

9 of 238

Page 10: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE19355 $754.9319357 $1,508.0619361 $1,568.8019364 $2,743.8619366 $1,392.7219367 $1,779.9519368 $2,189.9619369 $2,033.0419370 $686.9619371 $785.3019380 $775.1819396 $291.4220100 $598.0220101 $455.9220102 $492.8020103 $585.0020150 $1,001.5220200 $208.9820205 $291.4220206 $241.1620220 $171.3820225 $528.9620240 $150.0520245 $349.6320250 $390.8420251 $422.3020500 $109.5520501 $129.8020520 $207.9020525 $482.3220526 $77.0120527 $83.5220550 $53.1520551 $53.8720552 $55.6820553 $64.0020555 $330.8320600 $48.4520604 $74.1220605 $50.6220606 $81.7120610 $59.6620611 $91.8420612 $60.38

10 of 238

Page 11: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE20615 $246.2220650 $214.0420660 $235.0120661 $495.3320662 $511.6020663 $470.3920664 $846.4120665 $111.3620670 $381.4420680 $620.4320690 $593.6820692 $1,119.7520693 $444.3520694 $428.4520696 $1,193.1420697 $2,129.5820802 $2,735.5520805 $3,254.3820808 $3,933.7520816 $2,048.9520822 $1,762.9620824 $2,052.5620827 $1,804.9020838 $2,770.6220900 $415.4320902 $282.0220910 $467.8620912 $475.4520920 $399.5220922 $590.7920924 $506.1820926 $420.4920931 $107.7420932 $708.6520933 $650.0820934 $708.2920936 $240.0220937 $164.1520938 $179.6920939 $66.8920950 $264.3020955 $2,483.9020956 $2,620.2120957 $2,736.99

11 of 238

Page 12: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE20962 $2,651.6720969 $2,744.9520970 $2,833.5320972 $2,836.4220973 $2,995.1520974 $78.4620975 $176.0820979 $52.4320982 $3,968.1020983 $5,909.3020985 $144.9821010 $765.7821011 $357.2221012 $337.7021013 $527.5121014 $521.0121015 $705.4021016 $1,008.3921025 $871.3521026 $599.4621029 $776.6321030 $515.5821031 $399.8821032 $402.4121034 $1,310.6521040 $519.2021044 $874.2521045 $1,222.0721046 $1,101.6721047 $1,308.8421048 $1,118.3021049 $1,207.6021050 $903.9021060 $821.4621070 $639.6021073 $389.0421076 $960.6621077 $2,392.4321079 $1,624.1221080 $1,837.0821081 $1,690.2821082 $1,580.7321083 $1,508.0621084 $1,726.44

12 of 238

Page 13: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE21085 $736.1321086 $1,777.0621087 $1,777.0621100 $705.7621110 $828.6921116 $181.5021120 $684.0721121 $735.4121122 $784.5821123 $912.5721125 $2,963.6921127 $4,021.6121137 $752.7621138 $918.3621139 $1,119.7521141 $1,371.0321142 $1,408.9921143 $1,470.4621145 $1,604.2321146 $1,670.0421147 $1,763.3221150 $1,661.7221151 $1,828.0421154 $1,966.5121155 $2,180.5621159 $2,611.5321160 $2,832.0821172 $1,999.7821175 $2,212.7321179 $1,516.0121180 $1,701.1321181 $740.8321182 $2,118.0121183 $2,312.1621184 $2,488.9721188 $1,675.4621193 $1,278.1121194 $1,470.8221195 $1,428.5221196 $1,469.3721198 $1,154.4521199 $1,072.7421206 $1,190.9721208 $1,772.72

13 of 238

Page 14: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE21209 $909.3221210 $2,147.2921215 $4,113.0821230 $743.7221235 $732.1521240 $1,116.8521242 $1,042.0121243 $1,699.6821244 $1,049.9621245 $1,224.2421246 $883.2921247 $1,636.7721248 $1,089.0121249 $1,570.2521255 $1,418.7521256 $1,244.1221260 $1,402.4821261 $2,477.7621263 $2,292.2821267 $1,638.5821268 $2,053.2921270 $1,020.6821275 $840.9821280 $581.3921282 $389.7621295 $189.8221296 $411.4521310 $134.5021315 $279.1221320 $257.0721325 $473.2821330 $569.8221335 $720.5921336 $647.9121337 $411.4521338 $665.9921339 $753.8521340 $744.0921343 $1,080.3421344 $1,383.3221345 $783.1321346 $934.6321347 $1,017.7921348 $1,080.70

14 of 238

Page 15: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE21355 $430.2521356 $504.7321360 $510.8821365 $1,110.3421366 $1,273.0521385 $756.3821386 $695.6421387 $788.5621390 $805.9121395 $1,009.4721400 $203.2021401 $522.8121406 $577.4121407 $649.3621408 $902.0921421 $718.0521422 $662.3721423 $774.4621431 $722.3921432 $720.5921433 $1,739.4621435 $1,403.2121436 $2,041.3621440 $617.1821445 $787.4721450 $583.9221451 $770.4821452 $686.2421453 $980.5521454 $546.6821461 $2,124.1521462 $2,261.1821465 $898.8321470 $1,200.7321480 $109.5521485 $846.7721490 $887.6221497 $696.3621501 $463.5221502 $496.0621510 $437.1221550 $264.6621552 $441.1021554 $722.75

15 of 238

Page 16: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE21555 $423.0221556 $525.3421557 $945.1121558 $1,328.0021600 $547.4021610 $1,151.5621615 $596.2121616 $694.5521620 $498.5921627 $533.6621630 $1,217.0021632 $1,184.1021685 $983.8021700 $347.1021705 $519.2021720 $501.1221725 $538.7221740 $1,007.3021750 $668.8821811 $581.3921812 $713.7221813 $960.3021820 $143.5421825 $534.3821920 $258.5121925 $457.3721930 $483.0421931 $464.2421932 $652.9721933 $728.1821935 $1,013.8121936 $1,397.0622010 $941.1422015 $931.7322100 $846.0522101 $843.1522102 $807.3622103 $137.3922110 $1,021.7622112 $1,073.4722114 $1,081.0622116 $137.0322206 $2,395.6822207 $2,356.27

16 of 238

Page 17: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE22208 $574.5222210 $1,751.3922212 $1,467.9322214 $1,472.6322216 $356.1322220 $1,586.5222222 $1,667.1422224 $1,566.2722226 $355.0522310 $305.5222315 $876.0622318 $1,581.0922319 $1,746.6922325 $1,415.8622326 $1,454.9122327 $1,475.1622328 $273.7022505 $130.8822510 $1,785.7322511 $1,768.7422512 $916.1922513 $7,043.8722514 $7,022.9022515 $4,078.0122526 $2,337.4722527 $1,968.3222532 $1,755.3622533 $1,638.5822534 $352.5222548 $1,881.9122551 $1,662.0822552 $386.5122554 $1,226.0422556 $1,634.6022558 $1,506.9722585 $319.9822586 $1,947.7122590 $1,533.7322595 $1,465.0322600 $1,258.9422610 $1,240.5122612 $1,558.6822614 $381.0822630 $1,531.20

17 of 238

Page 18: ND Medicaid PROFESSIONAL Fee Schedule-7-1-19 (updated-2)...1' 0(',&$,' 352)(66,21$/ 6(59,&(6 )(( 6&+('8/(DV RI ,QFOXVLRQ RU H[FOXVLRQ RI D SURFHGXUH FRGH VXSSO\ SURGXFW RU VHUYLFH

ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE22632 $310.9422633 $1,811.0422634 $483.0422800 $1,337.0422802 $2,073.5422804 $2,393.1522808 $1,810.6822810 $2,025.8122812 $2,183.8122818 $2,148.3822819 $2,463.6622830 $801.9422840 $741.1922842 $744.4522843 $796.5122844 $968.2522845 $709.0222846 $736.4922847 $800.1322848 $352.8822849 $1,274.8522850 $714.4422852 $686.9622853 $252.0122854 $326.1322855 $1,084.3122856 $1,597.7222857 $1,755.3622858 $497.1422859 $326.1322861 $2,173.3322862 $1,912.2822864 $1,980.2522865 $1,919.5122867 $953.7922868 $235.3722869 $462.7922870 $126.1822900 $556.4422901 $655.8722902 $447.9722903 $433.8722904 $1,040.9322905 $1,313.54

18 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE23000 $567.6523020 $687.3223030 $438.5723031 $405.6723035 $674.6723040 $714.8023044 $563.6723065 $223.0823066 $570.1823071 $415.0723073 $688.0423075 $487.7423076 $537.2823077 $1,120.8323078 $1,418.7523100 $500.0323101 $455.5623105 $636.3423106 $497.1423107 $658.4023120 $583.5523125 $703.9523130 $610.6723140 $550.6523145 $687.6823146 $614.6523150 $656.9523155 $787.4723156 $674.3123170 $559.6923172 $563.6723174 $756.0223180 $655.5023182 $657.3123184 $731.0723190 $569.8223195 $743.0023200 $1,502.2723210 $1,763.6823220 $1,936.1423330 $283.1023333 $461.3523334 $1,065.1523335 $1,269.43

19 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE23350 $142.0923395 $1,277.3823397 $1,128.0623400 $956.6823405 $616.4623406 $769.4023410 $817.4823412 $848.2223415 $696.0023420 $966.8123430 $741.9223440 $750.5923450 $938.9723455 $991.3923460 $1,080.3423462 $1,048.5223465 $1,109.6223466 $1,110.3423470 $1,193.1423472 $1,445.5123473 $1,611.8323474 $1,740.1823480 $817.4823485 $949.0923490 $854.0023491 $1,009.1123500 $219.4723505 $355.0523515 $717.3323520 $235.3723525 $389.4023530 $569.0923532 $618.6323540 $229.9523545 $348.9023550 $567.6523552 $652.2523570 $232.1223575 $403.5023585 $974.0423600 $329.7423605 $466.0523615 $880.3923616 $1,232.19

20 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE23620 $269.0023625 $382.1723630 $778.0723650 $320.3423655 $403.1423660 $581.0223665 $428.4523670 $871.7223675 $550.2923680 $924.1423700 $195.6023800 $1,018.5123802 $1,271.9623900 $1,376.4523920 $1,119.3823921 $467.4923930 $357.5823931 $290.6923935 $507.6324000 $476.5324006 $712.6324065 $262.1324066 $633.4524071 $402.0524073 $686.9624075 $507.6324076 $541.2524077 $1,026.1024079 $1,309.2024100 $416.5124101 $500.0324102 $615.3724105 $353.2424110 $584.6424115 $729.9924116 $856.1724120 $530.0424125 $619.3524126 $643.5724130 $509.8024134 $743.3624136 $629.1124138 $675.7524140 $700.70

21 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE24145 $590.4224147 $622.9624149 $1,173.9824150 $1,542.4124152 $1,329.0924155 $846.0524160 $1,257.8624164 $723.8424200 $213.3224201 $555.3524220 $168.1224300 $424.1124301 $747.7024305 $577.7724310 $468.2224320 $773.0124330 $713.7224331 $774.1024332 $611.3924340 $610.6724341 $744.4524342 $773.3724343 $709.0224344 $1,090.1024345 $703.5924346 $1,092.6324357 $419.4124358 $523.5424359 $659.4824360 $895.5824361 $1,001.1524362 $1,054.6624363 $1,447.6824365 $636.3424366 $679.3724370 $1,542.0424371 $1,771.2724400 $820.3824410 $1,052.1324420 $991.3924430 $1,049.9624435 $1,072.7424470 $669.2424495 $741.19

22 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE24498 $861.9524500 $359.0324505 $499.3124515 $874.2524516 $855.8124530 $381.0824535 $616.8224538 $744.4524545 $925.5924546 $1,034.4224560 $327.5724565 $535.4724566 $716.6124575 $730.7124576 $345.6524577 $551.3824579 $833.0324582 $809.1724586 $1,078.5324587 $1,081.0624600 $370.6024605 $472.9224615 $711.1824620 $552.8224635 $672.8624640 $101.9624650 $262.8524655 $444.3524665 $652.9724666 $731.4324670 $291.4224675 $459.1824685 $652.9724800 $823.9924802 $997.1824900 $732.8824920 $730.3524925 $564.7524930 $769.0324931 $928.1224935 $1,159.8825000 $339.8625001 $345.6525020 $575.24

23 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE25023 $1,106.7325024 $776.6325025 $1,201.1025028 $529.3225031 $349.2725035 $583.9225040 $560.7825065 $259.6025066 $359.0325071 $421.5825073 $531.8525075 $496.0625076 $517.7525077 $874.9725078 $1,156.2625085 $449.4225100 $346.3725101 $404.9425105 $484.4925107 $616.8225109 $538.3625110 $342.4025111 $321.7925112 $387.5925115 $757.8325116 $601.6325118 $382.1725119 $495.7025120 $498.5925125 $588.9825126 $593.6825130 $448.3325135 $555.3525136 $489.9125145 $515.5825150 $565.4825151 $581.3925170 $1,465.3925210 $489.1925215 $617.9025230 $433.5125240 $429.5325246 $174.2725248 $411.81

24 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE25250 $528.2425251 $715.5225259 $422.3025260 $630.2025263 $625.5025265 $746.6225270 $490.2725272 $554.2725274 $665.6325275 $669.9725280 $564.0325290 $436.7625295 $525.7125300 $681.5425301 $642.4925310 $619.7125312 $716.9725315 $765.0625316 $910.4025320 $985.9725332 $840.2625335 $938.9725337 $890.1625350 $673.5825355 $757.1025360 $654.0625365 $907.8725370 $1,003.3225375 $948.7325390 $768.3125391 $990.3125392 $993.2025393 $1,116.8525394 $778.0725400 $800.8525405 $1,034.7825415 $960.3025420 $1,158.4325425 $955.6025426 $1,117.5825430 $728.1825431 $783.5025440 $768.6725441 $931.01

25 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE25442 $807.0025443 $774.1025444 $821.4625445 $720.5925446 $1,170.3625447 $828.3325449 $1,029.7225450 $614.2925455 $723.8425490 $715.5225491 $736.4925492 $900.6425500 $277.6825505 $501.4825515 $667.8025520 $568.3725525 $786.3925526 $949.4525530 $263.2125535 $490.6325545 $622.6025560 $283.4625565 $515.5825574 $672.1425575 $898.8325600 $331.9125605 $540.5325606 $662.0125607 $733.9625608 $822.5425609 $1,046.3525622 $306.6025624 $482.6825628 $719.8625630 $305.8825635 $459.1825645 $566.5625650 $323.9625651 $486.3025652 $621.8825660 $413.9825670 $604.1625671 $528.2425675 $440.38

26 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE25676 $628.0325680 $520.2825685 $731.7925690 $482.6825695 $630.2025800 $729.9925805 $840.6225810 $867.0225820 $621.1625825 $764.3325830 $946.5625900 $709.0225905 $696.0025907 $607.7825909 $680.4525915 $1,163.1325920 $699.6125922 $615.3725924 $677.5625927 $807.7225929 $594.7625931 $744.0926010 $276.2326011 $408.9226020 $435.3226025 $421.9426030 $489.9126034 $544.1426035 $855.4526037 $565.4826040 $313.8326045 $469.3026055 $575.2426060 $258.1526070 $321.4326075 $334.8026080 $393.3826100 $335.8926105 $337.7026110 $323.5926111 $416.5126113 $547.7626115 $524.6226116 $526.43

27 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE26117 $741.1926118 $1,047.8026121 $597.6626123 $834.4826125 $271.5326130 $460.2626135 $551.7426140 $505.8226145 $513.4126160 $591.5126170 $407.8426180 $446.8926185 $550.2926200 $450.1426205 $600.5526210 $444.3526215 $562.5826230 $498.9526235 $492.8026236 $441.4626250 $1,063.3426260 $796.5126262 $629.1126320 $348.5426340 $341.3126341 $101.9626350 $706.1226352 $805.9126356 $796.1526357 $885.8226358 $978.7426370 $748.4326372 $871.7226373 $837.0126390 $823.9926392 $958.8526410 $559.6926412 $672.1426415 $803.0226416 $873.1626418 $574.1526420 $699.6126426 $501.4826428 $746.26

28 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE26432 $493.1726433 $523.9026434 $638.8726437 $616.8226440 $614.2926442 $953.7926445 $570.5426449 $696.0026450 $403.5026455 $399.8826460 $391.5726471 $610.3126474 $594.7626476 $587.1726477 $575.6026478 $613.2026479 $618.2626480 $745.1726483 $832.6726485 $797.6026489 $921.2526490 $784.9426492 $870.9926494 $787.1126496 $848.5826497 $852.5526498 $1,125.8926499 $817.4826500 $613.2026502 $700.3426508 $625.5026510 $589.7026516 $693.4726517 $810.9726518 $822.9126520 $641.7726525 $645.0226530 $537.6426531 $625.8626535 $430.9826536 $707.5726540 $650.0826541 $789.6426542 $671.77

29 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE26545 $696.7226546 $984.8826548 $750.5926550 $1,618.3326551 $3,255.1126553 $3,233.4126554 $3,771.7726555 $1,350.4226556 $3,361.4026560 $580.3026561 $929.9326562 $1,323.3026565 $668.5226567 $673.9426568 $886.9026580 $1,490.3426587 $1,035.1426590 $1,385.1326591 $437.1226593 $595.4926596 $749.5126600 $296.1226605 $325.4026607 $468.2226608 $479.0626615 $575.6026641 $378.1926645 $429.5326650 $480.1526665 $625.8626670 $346.7326675 $457.3726676 $505.1026685 $574.8826686 $620.0726700 $329.7426705 $420.4926706 $441.8226715 $573.4326720 $198.8626725 $339.5026727 $472.1926735 $595.4926740 $231.04

30 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE26742 $372.4026746 $741.9226750 $185.4826755 $316.7226756 $419.7726765 $502.2026770 $279.8526775 $386.5126776 $444.3526785 $547.7626820 $774.4626841 $718.7826842 $773.3726843 $727.8226844 $807.0026850 $684.0726852 $785.6726860 $560.4126861 $102.3226862 $718.0526863 $226.3426910 $714.4426951 $646.8326952 $637.7926990 $635.2626991 $709.0226992 $965.7227000 $409.2827001 $535.8327003 $592.5927005 $720.9527006 $721.6727025 $911.8527027 $882.2027030 $931.7327033 $967.1727035 $1,172.5327036 $1,006.5827040 $347.8227041 $694.9127043 $463.5227045 $734.6927047 $474.7327048 $604.89

31 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE27049 $1,322.5827050 $402.4127052 $575.9627054 $683.7127057 $1,005.1327059 $1,804.9027060 $463.8827062 $454.4827065 $518.4727066 $800.8527067 $1,029.7227070 $855.0827071 $923.7827075 $2,080.4027076 $2,516.4427077 $2,812.5627078 $2,051.4827080 $506.9027086 $305.1527087 $611.0327090 $827.2427091 $1,586.1527093 $204.6427095 $271.8927096 $162.7027097 $679.0127098 $692.0227100 $819.2927105 $861.5927110 $961.3827111 $896.6627120 $1,288.2327122 $1,095.1627125 $1,127.3427130 $1,346.4427132 $1,663.8927134 $1,900.7127137 $1,462.1427138 $1,518.9127140 $888.7127146 $1,269.4327147 $1,450.9327151 $1,579.6527156 $1,690.65

32 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE27158 $1,379.3427161 $1,207.2427165 $1,361.6327170 $1,164.9427175 $663.1027176 $912.5727177 $1,088.2927178 $915.4627179 $965.7227181 $1,100.2227185 $715.5227187 $988.5027197 $124.0127198 $300.4527200 $184.3927202 $525.3427215 $627.6627216 $930.6527217 $873.1627218 $1,204.3527220 $531.4927222 $967.8927226 $1,050.6927227 $1,649.0727228 $1,868.8927230 $478.3427232 $739.0227235 $904.2627236 $1,188.8027238 $460.9927240 $952.3427244 $1,223.5127245 $1,223.1527246 $386.5127248 $740.4727250 $177.1627252 $752.7627253 $937.8827254 $1,256.7827256 $303.7127257 $360.1127258 $1,103.4827259 $1,541.3227265 $402.78

33 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE27266 $579.5827267 $433.1527268 $536.9127269 $1,234.3627275 $183.3127279 $680.8127280 $1,328.7327282 $853.2827284 $1,588.6927286 $1,640.7527290 $1,613.9927295 $1,247.7427301 $677.2027303 $637.7927305 $479.7927306 $347.8227307 $478.7027310 $728.1827323 $279.1227324 $400.2427325 $555.7127326 $513.4127327 $474.7327328 $618.9927329 $1,026.1027330 $416.1527331 $474.0027332 $640.3227333 $584.6427334 $682.6227335 $759.9927337 $413.9827339 $745.8927340 $371.6827345 $480.1527347 $527.1527350 $648.6427355 $603.0827356 $735.0527357 $810.6127358 $275.1527360 $858.3427364 $1,548.9127365 $2,048.95

34 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE27369 $145.3527372 $600.5527380 $596.9327381 $797.6027385 $578.1327386 $831.5827390 $447.2527391 $573.0727392 $707.5727393 $508.7127394 $644.6627395 $873.5227396 $612.1227397 $910.4027400 $688.4127403 $638.5127405 $673.9427407 $784.9427409 $957.4127412 $1,630.6327415 $1,346.4427416 $969.3427418 $824.7127420 $740.1127422 $740.1127424 $744.0927425 $449.0627427 $709.7427428 $1,108.9027429 $1,246.6527430 $736.8627435 $805.9127437 $657.6727438 $835.9227440 $792.5427441 $820.0127442 $864.8527443 $809.5327445 $1,245.2127446 $1,151.5627447 $1,345.7227448 $775.9027450 $1,011.2827454 $1,288.23

35 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE27455 $935.3527457 $955.2427465 $1,244.4827466 $1,174.7027468 $1,335.2327470 $1,171.0927472 $1,255.3327475 $659.8427477 $730.7127479 $915.4627485 $668.5227486 $1,397.7827487 $1,746.3327488 $1,194.5927495 $1,120.8327496 $543.4227497 $578.8527498 $652.2527499 $696.3627500 $519.5627501 $503.2927502 $754.9327503 $796.1527506 $1,330.8927507 $966.0827508 $523.5427509 $648.2727510 $679.7327511 $990.6727513 $1,231.4727514 $961.7427516 $510.5227517 $680.8127519 $886.1827520 $323.9627524 $749.1527530 $303.7127532 $615.0127535 $892.6927536 $1,182.2927538 $477.9827540 $810.6127550 $519.9227552 $625.86

36 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE27556 $870.6327557 $1,037.3127558 $1,181.2127560 $368.4327562 $483.0427566 $886.9027570 $150.7727580 $1,434.6627590 $779.1627591 $959.5727592 $669.9727594 $501.8427596 $707.5727598 $700.7027600 $401.6927601 $443.2727602 $475.8127603 $534.7427604 $481.9627605 $352.1627606 $278.7627607 $609.2327610 $650.4427612 $570.9027613 $254.9027614 $582.8327615 $1,017.0627616 $1,258.9427618 $466.0527619 $464.6027620 $454.1227625 $573.4327626 $611.3927630 $564.7527632 $410.7327634 $675.0327635 $581.0227637 $745.1727638 $764.3327640 $830.1427641 $663.8227645 $1,765.1327646 $1,529.0327647 $1,038.03

37 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE27648 $186.5627650 $660.5727652 $678.6427654 $713.7227656 $643.2127658 $374.5727659 $476.5327664 $364.0927665 $417.2427675 $494.2527676 $602.3627680 $425.9227681 $546.6827685 $673.9427686 $546.6827687 $457.3727690 $643.5727691 $747.3427692 $103.7727695 $477.2627696 $558.2527698 $639.9627700 $615.7327702 $959.9427703 $1,107.0927704 $574.1527705 $757.8327707 $401.6927709 $1,160.9627712 $1,094.0727715 $1,064.4327720 $871.3527722 $885.8227724 $1,256.4127725 $1,210.8627726 $956.3227727 $1,015.6227730 $585.3627732 $448.3327734 $654.4227740 $705.7627742 $775.1827745 $752.0427750 $346.73

38 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE27752 $535.4727756 $577.0527758 $889.0727759 $993.9227760 $334.8027762 $477.6227766 $605.9727767 $284.5527768 $441.1027769 $726.7327780 $306.9627781 $430.6227784 $713.7227786 $316.0027788 $424.1127792 $648.6427808 $335.8927810 $468.9427814 $767.2327816 $326.8527818 $487.0227822 $858.3427823 $971.5127824 $316.3627825 $547.0427826 $843.1527827 $1,099.8627828 $1,309.5627829 $696.0027830 $383.6127831 $402.4127832 $752.0427840 $375.3027842 $489.5527846 $719.1427848 $796.8727860 $171.7427870 $1,023.9327871 $686.9627880 $894.1327881 $851.8327882 $585.3627884 $561.5027886 $646.10

39 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE27888 $656.2327889 $634.1727892 $547.0427893 $608.1427894 $836.6528001 $286.3528002 $454.1228003 $714.0828005 $586.8128008 $445.8028010 $237.9128011 $324.3228020 $552.8228022 $500.0328024 $468.2228035 $543.0628039 $510.1628041 $459.9028043 $409.2828045 $506.5428046 $731.0728047 $1,049.6028050 $437.8528052 $455.2028054 $387.9528055 $389.0428060 $534.3828062 $600.9128070 $549.2128072 $502.5728080 $541.6128086 $557.5228088 $463.5228090 $484.1328092 $439.2928100 $626.5828102 $604.5228103 $399.1628104 $547.4028106 $437.8528107 $531.4928108 $454.4828110 $479.4328111 $502.57

40 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE28112 $502.2028113 $606.3328114 $1,085.7628116 $780.9728118 $612.4828119 $538.7228120 $692.0228122 $613.2028124 $493.5328126 $407.8428130 $642.8528140 $604.1628150 $436.4028153 $426.6428160 $429.8928171 $1,108.1828173 $754.2128175 $485.9328190 $262.8528192 $481.9628193 $547.7628200 $507.6328202 $622.6028208 $494.6128210 $604.8928220 $466.7728222 $532.2128225 $433.1528226 $623.6928230 $449.0628232 $399.5228234 $421.9428238 $685.8828240 $470.0328250 $591.5128260 $702.1528261 $1,046.3528262 $1,411.5228264 $1,016.7028270 $507.9928272 $405.6728280 $528.9628285 $551.7428286 $463.52

41 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE28288 $625.8628289 $749.1528291 $749.1528292 $761.0828295 $984.5228296 $940.0528297 $1,077.0828298 $873.1628299 $1,040.2028300 $652.2528302 $711.9128304 $835.9228305 $667.0728306 $626.9428307 $659.8428308 $584.6428309 $891.2428310 $560.4128312 $518.1128313 $533.6628315 $496.0628320 $613.9328322 $799.4028340 $595.1228341 $689.4928344 $441.1028345 $538.3628360 $1,085.0428400 $250.5628405 $395.1828406 $528.6028415 $1,118.3028420 $1,269.4328430 $240.8028435 $365.1728436 $453.0328445 $1,050.6928446 $1,215.2028450 $215.8528455 $293.2228456 $324.6828465 $635.9828470 $221.6428475 $259.96

42 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE28476 $356.1328485 $551.0128490 $146.4328495 $182.5928496 $472.5628505 $678.2828510 $124.7428515 $166.3228525 $584.2828530 $118.9528531 $353.2428540 $198.5028545 $301.9028546 $591.8728555 $876.4228570 $230.3128575 $370.9628576 $391.9328585 $886.5428600 $222.0028605 $334.0828606 $392.6528615 $813.1428630 $158.7228635 $180.0628636 $327.2128645 $672.5028660 $119.6828665 $157.6428666 $160.8928675 $583.9228705 $1,236.1728715 $942.5828725 $782.0528730 $738.3028735 $784.2228737 $701.7828740 $858.7028750 $817.4828755 $524.2628760 $810.9728800 $538.3628805 $728.5428810 $429.17

43 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE28820 $572.7128825 $549.2128890 $332.6329000 $342.4029010 $272.6129015 $292.5029035 $255.6229040 $292.1429044 $286.3529046 $313.8329049 $99.0729055 $221.2729058 $122.9329065 $95.8129075 $86.7729085 $95.4529086 $79.9029105 $82.4429125 $65.0829126 $77.3729130 $41.2229131 $51.7029200 $32.5429240 $31.0929260 $30.3729280 $31.0929305 $246.9429325 $272.2529345 $135.2229355 $141.3729358 $159.8129365 $122.5729405 $80.9929425 $77.7329435 $117.5129440 $44.1129445 $131.6129450 $146.7929505 $86.4129515 $71.9529520 $34.7129530 $30.7329540 $29.2929550 $19.52

44 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE29580 $63.2729581 $88.9429584 $82.8029700 $64.3629705 $64.7229710 $122.5729720 $84.9729730 $62.9129740 $98.3429750 $106.6629800 $526.7929804 $641.4029805 $470.3929806 $1,054.6629807 $1,031.1629819 $584.2829820 $534.3829821 $586.8129822 $570.1829823 $620.0729824 $668.5229825 $578.8529826 $173.5529827 $1,055.7529828 $908.6029830 $455.5629834 $487.3829835 $504.0129836 $574.1529837 $524.9829838 $588.2529840 $450.8629843 $482.6829844 $498.5929845 $579.5829846 $521.3729847 $536.9129848 $511.9729850 $621.1629851 $925.2329855 $780.6029856 $987.4129860 $661.2929861 $717.33

45 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE29862 $806.6429863 $807.3629866 $1,046.7129867 $1,269.0729868 $1,664.6129870 $577.0529871 $513.4129873 $526.7929874 $535.1129875 $494.6129876 $654.0629877 $619.7129879 $660.2029880 $560.7829881 $540.1729882 $694.5529883 $841.7129884 $614.2929885 $745.5329886 $635.2629887 $745.8929888 $978.7429889 $1,217.0029891 $673.9429892 $660.9329893 $639.2329894 $496.4229895 $471.8329897 $504.7329898 $565.1229899 $1,031.1629900 $497.5029901 $532.5729902 $567.6529904 $631.6429905 $528.9629906 $679.0129907 $871.7229914 $983.0829915 $1,014.1729916 $1,011.6430000 $243.3330020 $245.8630100 $142.45

46 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE30110 $236.4630115 $440.3830117 $919.4430118 $776.6330120 $517.0330124 $288.5230125 $617.9030130 $390.4830140 $279.4830150 $774.1030160 $779.5230200 $113.1730210 $151.1330220 $306.9630300 $188.0130310 $203.9230320 $460.2630400 $1,091.5430410 $1,258.2230420 $1,384.0430430 $963.5530435 $1,189.5330450 $1,574.2230460 $821.1030462 $1,576.3930465 $987.0530520 $635.6230540 $698.8930545 $953.7930560 $284.5530580 $643.9330600 $568.7330620 $644.3030630 $635.9830801 $225.9730802 $285.2730901 $138.8430903 $219.1030905 $334.0830906 $348.1830915 $579.9430920 $842.0730930 $121.1231000 $184.03

47 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE31002 $191.2631020 $487.7431030 $676.4831032 $580.6631040 $773.3731050 $491.3631051 $656.2331070 $447.6131075 $789.6431080 $1,039.1231081 $1,117.9431084 $1,156.6231085 $1,197.1231086 $1,128.7831087 $1,082.8731090 $1,047.0731200 $597.2931201 $756.0231205 $928.8431225 $1,843.5831230 $2,036.6631231 $203.2031233 $262.8531235 $300.4531237 $256.3431238 $252.7331239 $620.0731240 $158.7231241 $444.3531253 $500.7631254 $415.7931255 $323.9631256 $180.4231257 $446.5231259 $472.9231267 $265.3831276 $378.5531287 $201.3931288 $234.2931290 $1,139.6331291 $1,207.9731292 $988.1431293 $1,072.3831294 $1,226.77

48 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE31295 $2,004.8431296 $2,030.5131297 $1,991.1031298 $3,844.0831300 $1,286.4231360 $2,089.4431365 $2,574.6531367 $2,213.4631368 $2,457.5131370 $2,083.6631375 $1,975.5531380 $1,949.8831382 $2,137.8931390 $2,860.2931395 $3,021.9031400 $989.5831420 $825.4431500 $141.0131502 $35.0731505 $85.3331510 $212.9631511 $211.8731512 $208.9831513 $130.8831515 $205.3631520 $155.8331525 $251.2831526 $156.1931527 $194.1631528 $143.5431529 $160.5331530 $198.1331531 $211.5131535 $188.3731536 $210.0731540 $240.0731541 $262.1331545 $360.8331546 $547.4031551 $1,440.8131552 $1,450.2131553 $1,586.5231554 $1,661.0031560 $311.30

49 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE31561 $340.9531570 $338.4231571 $248.0331572 $513.7731573 $269.3631574 $1,035.1431575 $117.5131576 $268.2831577 $279.8531578 $304.7931579 $184.7631580 $1,258.5831584 $1,392.0031587 $1,164.5831590 $887.6231591 $1,055.7531592 $1,709.4531600 $304.7931601 $450.1431603 $319.2631605 $328.6631610 $954.1531611 $535.8331612 $84.2431613 $445.4431614 $740.1131615 $170.6631622 $242.9731623 $267.9131624 $252.7331625 $342.4031626 $858.3431627 $1,364.1631628 $363.3731629 $449.7831630 $198.8631631 $228.5031632 $64.0031633 $80.2731634 $1,779.5931635 $284.5531636 $221.2731637 $77.7331638 $251.64

50 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE31640 $252.3731641 $258.5131643 $178.9731645 $263.9431646 $143.5431647 $212.9631648 $201.3931649 $68.3331651 $74.8431652 $984.5231653 $1,031.1631654 $125.4631660 $198.1331661 $208.9831717 $285.6331720 $50.2631725 $79.9031730 $1,228.9431750 $1,388.3831755 $1,765.4931760 $1,339.9331766 $1,736.2031770 $1,295.4631775 $1,366.6931780 $1,192.4231781 $1,347.8931785 $1,073.8331786 $1,408.9931800 $726.3731805 $796.1531820 $435.6831825 $603.0831830 $449.0632035 $709.3832036 $762.8932096 $786.7532097 $786.0332098 $745.5332100 $792.9032110 $1,439.7232120 $854.7232124 $906.4332140 $968.6132141 $1,489.62

51 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE32150 $984.1632151 $979.8232160 $780.9732200 $1,112.1532215 $779.8832220 $1,553.6132225 $973.6832310 $893.7732320 $1,563.0232400 $156.9232405 $400.6132440 $1,529.3932442 $2,989.7232445 $3,448.9032480 $1,444.4232482 $1,545.3032484 $1,398.1432486 $2,296.9832488 $2,332.7732491 $1,442.2532501 $237.9132503 $1,753.9232504 $1,998.6932505 $911.4932506 $152.2232507 $152.2232540 $1,681.2432550 $760.7232551 $155.4732552 $184.0332553 $532.9432554 $214.0432555 $304.4332556 $624.7732557 $575.9632560 $255.2632561 $93.6432562 $83.8832601 $301.1832604 $468.5832606 $450.8632607 $300.8232608 $369.1532609 $253.09

52 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE32650 $653.3432651 $1,070.5732652 $1,622.6732653 $1,037.6732654 $1,136.0232655 $934.6332656 $784.2232658 $697.8132659 $716.9732661 $778.4332662 $873.5232663 $1,367.4132664 $828.6932665 $1,197.4832666 $851.8332667 $152.5832668 $152.5832669 $1,311.7332670 $1,565.5532671 $1,727.8932672 $1,489.2632673 $1,185.9132674 $209.7032701 $211.1532800 $919.8032810 $880.0332815 $2,736.2732820 $1,300.1632851 $3,212.0832852 $3,490.4832853 $4,486.9332854 $4,759.9132900 $1,389.4732905 $1,298.3532906 $1,608.2132940 $1,201.4632960 $128.3532994 $5,753.4732997 $346.7332998 $3,624.6233010 $105.2133011 $105.5733015 $505.4633020 $861.23

53 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE33025 $780.2433030 $1,953.8633031 $2,415.5733050 $982.7133120 $2,047.5033130 $1,342.1033140 $1,527.5833141 $127.9933202 $757.4633203 $792.9033206 $448.3333207 $475.0933208 $514.8633210 $161.2533211 $167.4033212 $317.4533213 $331.9133214 $473.6433215 $307.3233216 $367.7033217 $362.2833218 $384.3433220 $387.2333221 $356.5033222 $335.8933223 $404.9433224 $508.3533225 $462.4333226 $488.4633227 $334.8033228 $349.9933229 $370.6033230 $378.1933231 $396.9933233 $229.2333234 $480.5133235 $631.2833236 $764.7033237 $822.9133238 $923.4233240 $361.2033241 $213.6833243 $1,343.9133244 $853.64

54 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE33249 $906.4333250 $1,420.2033251 $1,587.2433254 $1,326.5633255 $1,599.1733256 $1,898.9033257 $571.6233258 $641.0433259 $829.4133261 $1,581.0933262 $368.7933263 $384.3433264 $400.6133265 $1,331.6233266 $1,807.7933270 $560.4133271 $449.7833272 $343.4833273 $396.9933274 $483.7633275 $512.3333285 $5,275.1333286 $131.6133289 $322.5133300 $2,396.0433305 $4,008.2333310 $1,148.6733315 $1,869.2533320 $1,034.4233321 $1,157.3533322 $1,356.9333330 $1,398.5133335 $1,844.6733340 $778.4333361 $1,330.1733362 $1,451.6633363 $1,503.0033364 $1,550.3633365 $1,744.8833366 $1,886.2533367 $614.6533368 $728.9033369 $962.1133390 $1,889.50

55 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE33391 $2,234.7933404 $1,721.0233405 $2,219.2433406 $2,810.0333410 $2,487.8833411 $3,282.9533412 $3,078.3033413 $3,143.0233414 $2,094.1433415 $1,990.7433416 $1,979.8933417 $1,629.1833418 $1,773.0833419 $417.9633420 $1,428.1533422 $1,627.7333425 $2,669.3833426 $2,330.9633427 $2,391.3433430 $2,738.4433440 $3,312.5933460 $2,348.6833463 $3,022.2633464 $2,389.5433465 $2,695.7833468 $2,371.1033470 $1,212.6733471 $1,297.2733474 $2,132.4733475 $2,283.2433476 $1,472.9933477 $1,338.1333478 $1,535.9033496 $1,632.8033500 $1,527.5833501 $1,094.8033502 $1,244.8433503 $1,300.8933504 $1,425.2633505 $1,987.1233506 $1,971.9433507 $1,679.0833508 $15.9133510 $1,891.67

56 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE33511 $2,077.1533512 $2,363.5033513 $2,432.2033514 $2,559.4733516 $2,643.3533517 $182.2333518 $401.6933519 $531.1333521 $637.0733522 $715.1633523 $808.0833530 $513.0533533 $1,828.7633534 $2,149.8233535 $2,397.4933536 $2,575.0233542 $2,569.9533545 $3,011.4233548 $2,898.9733572 $224.5333600 $1,672.9333602 $1,623.4033606 $1,740.9033608 $1,763.3233610 $1,739.0933611 $1,909.7533612 $1,960.7333615 $1,954.9433617 $2,086.1933619 $2,676.2533620 $1,610.3833621 $912.2133622 $3,359.9633641 $1,600.2633645 $1,686.6733647 $1,766.2133660 $1,710.5333665 $1,873.2333670 $1,930.3633675 $1,911.2033676 $1,981.3433677 $2,057.2733681 $1,795.8633684 $1,848.65

57 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE33688 $1,843.9533690 $1,177.2333692 $1,914.4533694 $1,909.7533697 $2,010.9933702 $1,501.9133710 $2,008.4533720 $1,511.3133722 $1,592.6633724 $1,497.2133726 $1,990.0233730 $1,933.9733732 $1,567.7233735 $1,270.8833736 $1,355.8433737 $1,272.3233750 $1,236.8933755 $1,291.1233762 $1,256.0533764 $1,291.1233766 $1,305.5933767 $1,393.8133768 $406.3933770 $2,071.3733771 $2,130.6633774 $1,762.9633775 $1,815.7433776 $1,881.9133777 $1,851.9033778 $2,299.8733779 $2,275.6533780 $2,269.8633781 $2,261.9133782 $3,159.6633783 $3,415.2833786 $2,227.9233788 $1,501.1933800 $961.0233802 $1,064.4333803 $1,127.7033813 $1,181.5733814 $1,492.8733820 $943.6733822 $1,001.15

58 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE33824 $1,156.9933840 $1,215.2033845 $1,293.2933851 $1,247.3833852 $1,331.9833853 $1,769.1033860 $3,143.0233863 $3,080.1133864 $3,154.2333866 $1,011.6433870 $2,475.5933875 $2,684.2133877 $3,529.8933880 $1,751.0333881 $1,503.0033883 $1,091.1833884 $381.4433886 $934.9933889 $765.7833891 $928.1233910 $2,575.0233915 $1,346.4433916 $4,146.7133917 $1,424.9033920 $1,772.3633922 $1,353.6733924 $276.9533925 $1,680.8833926 $2,364.5933927 $2,491.1333935 $4,829.3333945 $4,756.6633946 $304.4333947 $336.9733948 $237.5433949 $229.9533951 $415.7933952 $419.0533953 $464.9633954 $467.1333955 $814.2333956 $815.3133957 $181.1433958 $180.78

59 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE33959 $229.9533962 $229.2333963 $459.1833964 $481.6033965 $181.1433966 $233.2033967 $254.9033968 $33.2633969 $267.9133970 $346.7333971 $696.0033973 $505.4633974 $874.9733975 $1,277.0233976 $1,554.7033977 $1,102.0333978 $1,308.4833979 $1,905.4133980 $1,743.7933981 $816.0433982 $1,915.5333983 $2,256.4833984 $278.0433985 $504.3733986 $510.5233987 $203.9233988 $759.2733989 $478.3433990 $418.3233991 $613.9333992 $195.6033993 $172.4634001 $940.0534051 $972.2334101 $584.6434111 $587.5334151 $1,361.9934201 $1,001.8834203 $927.4034401 $1,438.6434421 $719.8634451 $1,381.8734471 $1,043.8234490 $628.39

60 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE34501 $861.5934502 $1,515.2934510 $988.1434520 $953.0734530 $888.3534701 $1,208.6934702 $1,807.0734703 $1,354.4034704 $2,258.6534705 $1,495.0434706 $2,251.0634707 $1,129.1534708 $1,814.6634709 $314.9234710 $786.0334711 $290.6934712 $677.2034713 $126.5534714 $266.1134715 $298.6534716 $369.5134808 $203.9234812 $201.0334813 $229.2334820 $338.4234830 $1,702.9434831 $1,881.9134832 $1,817.9134833 $392.6534834 $125.4635001 $1,086.1235002 $1,095.5235005 $962.4735011 $979.1035013 $1,225.3235021 $1,233.2735022 $1,391.6435045 $961.7435081 $1,688.1135082 $2,130.3035091 $1,738.0135092 $2,533.8035102 $1,830.9335103 $2,181.64

61 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE35111 $1,280.6435112 $1,581.0935121 $1,626.6535122 $1,829.1235131 $1,353.3135132 $1,577.4835141 $1,076.0035142 $1,296.5535151 $1,207.2435152 $1,344.2735180 $860.1535182 $1,751.3935184 $932.4635188 $1,227.1335189 $1,453.1035190 $744.8135201 $923.4235206 $768.6735207 $754.9335211 $1,354.7635216 $2,021.8335221 $1,433.2235226 $814.9535231 $1,227.8535236 $982.7135241 $1,408.9935246 $1,531.5635251 $1,700.7735256 $1,001.1535261 $948.3735266 $848.5835271 $1,354.4035276 $1,430.3235281 $1,577.8435286 $909.6835301 $1,103.8435302 $1,093.7135303 $1,209.7735304 $1,245.2135305 $1,198.9335306 $429.8935311 $1,524.3335321 $871.7235331 $1,424.54

62 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE35341 $1,343.1935351 $1,247.3835355 $1,004.7735361 $1,469.7335363 $1,569.8835371 $798.3235372 $955.2435390 $154.7535400 $144.6235500 $311.3035501 $1,458.1635506 $1,230.0235508 $1,274.4935509 $1,364.5235510 $1,186.6335511 $1,071.6635512 $1,167.1135515 $1,245.5735516 $1,180.8535518 $1,100.2235521 $1,185.9135522 $1,176.8735523 $1,251.7135525 $1,113.9635526 $1,702.2235531 $1,882.6335533 $1,454.5535535 $1,841.4135536 $1,635.3335537 $2,007.7335538 $2,250.3435539 $2,112.2235540 $2,364.9535556 $1,363.4435558 $1,200.0135560 $1,636.0535563 $1,280.6435565 $1,281.7235566 $1,625.2035570 $1,470.4635571 $1,289.3235572 $337.3335583 $1,407.1835585 $1,629.54

63 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE35587 $1,329.4535600 $249.8435601 $1,361.2735606 $1,144.3335612 $1,007.6635616 $1,063.3435621 $1,068.0435623 $1,269.7935626 $1,551.0835631 $1,803.8135632 $1,738.7335633 $1,939.4035634 $1,706.5535636 $1,542.7735637 $1,602.4335638 $1,712.3435642 $955.9635645 $916.5535646 $1,672.5735647 $1,514.2035650 $1,057.9235654 $1,334.1535656 $1,055.3935661 $1,059.3635663 $1,176.8735665 $1,145.0535666 $1,234.7235671 $1,088.6535681 $78.4635682 $342.4035683 $395.1835685 $192.7135686 $155.4735691 $915.4635693 $800.1335694 $955.2435695 $986.6935697 $143.9035700 $148.2435701 $566.2035721 $447.9735741 $510.5235761 $390.4835800 $713.35

64 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE35820 $1,969.0435840 $1,174.3435860 $818.5735870 $1,202.5435875 $582.1135876 $924.1435879 $903.9035881 $992.8435883 $1,170.7235884 $1,198.5635901 $458.4635903 $553.9135905 $1,620.8635907 $1,854.7936000 $27.4836002 $157.6436005 $314.1936010 $510.1636011 $860.8736012 $877.1436013 $784.5836014 $826.8836015 $896.6636100 $523.9036140 $454.1236160 $523.1736200 $577.0536215 $1,053.2236216 $1,129.1536217 $1,900.3536218 $246.2236221 $1,046.3536222 $1,235.8136223 $1,566.6336224 $2,028.3436225 $1,508.0636226 $1,917.7036227 $252.7336228 $1,342.1036245 $1,340.6636246 $844.2436247 $1,523.2436248 $146.7936251 $1,403.21

65 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE36252 $1,509.5036253 $2,250.3436254 $2,171.1636260 $639.9636261 $398.4436262 $305.1536400 $26.7636405 $23.5036406 $16.9936410 $17.3536415 $3.2536416 $7.2336420 $46.2836425 $40.1336430 $35.4336440 $51.7036450 $174.6336455 $123.6536456 $105.2136460 $343.1236465 $1,569.8836466 $1,648.3436470 $107.0236471 $193.4336473 $1,485.2836474 $278.4036475 $1,449.8536476 $300.0936478 $1,143.9736479 $318.1736481 $1,993.2736482 $2,085.1036483 $148.2436500 $181.5036510 $83.5236511 $109.9136512 $110.2836513 $110.2836514 $738.3036516 $2,030.1536522 $2,211.2936555 $190.1836556 $213.3236557 $1,031.52

66 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE36558 $774.8236560 $1,318.9636561 $1,091.1836563 $1,224.2436565 $877.8636566 $4,888.2636568 $92.9236569 $95.4536570 $1,457.4436571 $1,281.3636572 $427.7236573 $402.0536575 $164.5136576 $327.5736578 $463.1636580 $219.1036581 $770.1236582 $1,011.6436583 $1,277.7536584 $351.8036585 $1,089.7436589 $164.8736590 $220.5536591 $24.9536592 $27.8436593 $31.8236595 $618.9936596 $127.2736597 $131.2536598 $118.2336600 $31.0936620 $44.8336625 $104.8536640 $116.7836660 $70.1436680 $58.2136800 $122.2136810 $209.7036815 $131.2536818 $679.3736819 $715.1636820 $718.4236821 $650.0836823 $1,369.58

67 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE36825 $778.4336830 $652.9736831 $603.0836832 $740.1136833 $795.0736835 $471.1136838 $1,115.4136860 $251.2836861 $135.2236901 $654.7836902 $1,293.6536903 $5,487.3736904 $1,902.8836905 $2,394.9636906 $6,721.7236907 $731.7936908 $2,448.8336909 $1,977.7237140 $2,274.9237145 $2,110.0537160 $2,168.2637180 $2,084.3837181 $2,274.9237182 $835.9237183 $6,148.2937184 $2,149.1037185 $660.2037186 $1,338.4937187 $1,989.6537188 $1,676.1837191 $2,518.9737192 $1,328.3637193 $1,577.1237197 $1,553.6137200 $221.2737211 $383.2537212 $336.9737213 $232.8437214 $122.5737215 $985.2537216 $1,018.5137217 $1,058.2837218 $804.4737220 $3,000.21

68 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE37221 $4,263.1337222 $805.1937223 $2,248.5337224 $3,609.8037225 $12,442.3037226 $10,791.7837227 $16,035.1037228 $5,238.9837229 $12,443.0237230 $10,585.7037231 $15,227.7437232 $1,112.1537233 $1,349.3337234 $3,948.2137235 $4,277.9537236 $3,644.8737237 $2,166.8237238 $3,694.4037239 $1,760.4337241 $4,941.0537242 $7,624.5437243 $9,875.9637244 $7,053.6437246 $2,124.8837247 $808.0837248 $1,518.1837249 $599.4637252 $1,287.5137253 $197.4137500 $616.4637565 $711.9137600 $726.0137605 $713.7237606 $686.9637607 $368.0737609 $310.5837615 $517.3937616 $1,086.4837617 $1,316.7937618 $379.6437619 $1,689.9237650 $445.4437660 $1,288.5937700 $241.16

69 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE37718 $423.0237722 $464.6037735 $563.6737760 $612.8437761 $532.2137765 $643.5737766 $763.2537780 $228.8737785 $349.2737788 $1,279.5537790 $493.8938100 $1,133.8538101 $1,138.5538102 $258.5138115 $1,258.2238120 $1,036.9538200 $134.8638204 $105.2138205 $84.6038206 $84.6038207 $46.6438208 $29.6538209 $12.6538210 $83.1638211 $74.8438212 $49.5338213 $12.6538214 $42.6638215 $49.5338220 $167.7638221 $157.2838222 $174.2738230 $203.9238232 $198.8638240 $231.7638241 $173.1938242 $122.5738243 $123.2938300 $322.8738305 $479.4338308 $445.0838380 $569.4538381 $787.1138382 $662.37

70 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE38500 $331.9138505 $126.9138510 $519.2038520 $459.9038525 $431.7038530 $554.9938531 $434.5938542 $516.3038550 $505.8238555 $993.9238562 $703.9538564 $697.8138570 $508.3538571 $669.6138572 $919.0838573 $1,162.7738700 $803.0238720 $1,335.2338724 $1,446.2338740 $686.6038745 $865.2138746 $209.3438747 $262.1338760 $831.9438765 $1,283.5338770 $811.3438780 $1,028.9938790 $82.8038792 $83.1638794 $303.3538900 $134.8639000 $491.7239010 $771.9339200 $850.7539220 $1,112.8839401 $302.6239402 $395.5439501 $838.8139503 $5,779.1439540 $855.4539541 $924.5039545 $873.5239560 $788.2039561 $1,221.34

71 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE40490 $126.9140500 $518.1140510 $492.0840520 $499.3140525 $553.1840527 $618.2640530 $547.7640650 $461.3540652 $504.3740654 $581.3940700 $1,011.2840701 $1,197.1240702 $1,004.7740720 $1,032.6140761 $1,087.5740800 $216.5740801 $313.1140804 $194.8840805 $314.1940806 $104.1340808 $191.6340810 $212.9640812 $293.5940814 $391.5740816 $407.4840818 $373.8540819 $320.3440820 $269.0040830 $276.9540831 $353.2440840 $827.9740842 $800.8540843 $1,052.5040844 $1,374.6440845 $1,477.3341000 $164.5141005 $225.6141006 $359.3941007 $352.8841008 $391.2141009 $418.6841010 $210.7941015 $424.4741016 $451.95

72 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE41017 $458.8241018 $518.4741019 $487.3841100 $174.9941105 $177.5241108 $155.1141110 $220.5541112 $341.6741113 $371.3241114 $632.0041115 $254.9041116 $338.7841120 $1,088.6541130 $1,338.4941135 $2,199.0041140 $2,209.4841145 $2,795.2041150 $2,223.9441153 $2,408.3441155 $3,042.8741250 $279.1241251 $310.9441252 $322.5141510 $462.0741512 $669.6141520 $358.6741530 $983.8041800 $296.8441805 $295.3941806 $402.0541822 $288.8841823 $445.4441825 $219.8341826 $322.1541827 $453.7641828 $317.4541830 $403.5041872 $397.7141874 $395.5442000 $157.6442100 $151.1342104 $219.8342106 $275.8742107 $471.47

73 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE42120 $1,025.0242140 $273.3442145 $699.9842160 $237.5442180 $249.4842182 $325.4042200 $950.9042205 $990.3142210 $1,104.2042215 $723.4842220 $596.9342225 $1,000.0742226 $893.0542227 $838.8142235 $735.0542260 $826.5242280 $180.0642281 $231.4042300 $212.9642305 $429.5342310 $179.3342320 $255.9842330 $235.0142335 $394.4642340 $488.1042400 $105.2142405 $302.6242408 $520.2842409 $354.3342410 $622.6042415 $1,053.9442420 $1,183.7442425 $834.1142426 $1,347.1742440 $412.5442450 $458.8242500 $440.7442505 $562.9542507 $509.0742509 $838.4542510 $622.9642550 $148.6042600 $499.6742650 $81.71

74 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE42660 $125.1042665 $334.4442700 $192.3542720 $455.9242725 $816.4042800 $159.0942804 $201.0342806 $224.5342808 $229.9542809 $203.5642810 $391.9342815 $552.4642820 $289.9742821 $301.1842825 $263.2142826 $252.3742830 $208.9842831 $225.6142835 $194.1642836 $241.5242842 $1,021.4042844 $1,402.4842845 $2,248.5342860 $189.4642870 $601.9942890 $1,445.5142892 $1,896.0142894 $2,397.4942900 $336.2542950 $821.8242953 $985.9742955 $778.4342960 $168.4942961 $419.4142962 $518.4742970 $412.9042971 $455.9242972 $510.1643020 $551.3843030 $518.8443045 $1,275.5843100 $627.3043101 $984.1643107 $2,923.20

75 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE43108 $4,361.4743112 $3,430.1043113 $4,261.6843116 $4,883.5643117 $3,185.6943118 $3,553.0343121 $2,783.2743122 $2,507.7743123 $4,389.3143124 $3,722.6043130 $780.9743135 $1,438.6443180 $547.0443191 $155.4743192 $169.5743193 $169.5743194 $192.3543195 $185.1243196 $197.0543197 $189.0943198 $208.2643200 $231.4043201 $232.8443202 $327.2143204 $138.1243205 $143.9043206 $278.7643210 $432.4243211 $238.6343212 $190.1843213 $1,212.6743214 $194.8843215 $376.0243216 $380.0043217 $396.2743220 $1,064.7943226 $340.5943227 $636.7043229 $682.2643231 $348.5443232 $423.0243233 $231.4043235 $270.4543236 $356.50

76 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE43237 $199.9443238 $237.5443239 $363.0043240 $400.6143241 $144.9843242 $268.2843243 $241.5243244 $250.2043245 $578.8543246 $202.8343247 $363.0043248 $374.2143249 $1,078.1743250 $419.0543251 $463.8843252 $317.0943253 $268.2843254 $275.5143255 $671.0543257 $236.1043259 $231.0443260 $329.3843261 $345.6543262 $364.8143263 $364.8143264 $371.6843265 $442.1943266 $221.6443270 $702.1543273 $121.4843274 $472.1943275 $384.7043276 $491.7243277 $386.5143278 $441.8243279 $1,266.1843280 $1,062.2643281 $1,515.2943282 $1,702.5843283 $154.7543284 $636.7043285 $654.7843286 $3,113.0143287 $3,550.14

77 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE43288 $3,711.3943300 $616.4643305 $1,089.0143310 $1,449.8543312 $1,555.4243313 $2,675.5343314 $2,819.0743320 $1,370.6743325 $1,333.0643327 $807.0043328 $1,101.6743330 $1,311.0143331 $1,311.0143332 $1,137.8243333 $1,239.0643334 $1,223.1543335 $1,307.7643336 $1,482.3943337 $1,508.4243338 $113.5343340 $1,351.8743341 $1,372.4743351 $1,282.4543352 $1,046.3543360 $2,202.2543361 $2,646.6043400 $1,496.1343401 $1,514.5743405 $1,423.8243410 $1,025.7443415 $2,524.7643420 $1,015.2543425 $1,410.0843450 $167.0443453 $916.9143460 $216.9343500 $773.7343501 $1,324.3943502 $1,492.5143510 $931.7343520 $679.0143605 $826.1643610 $967.1743611 $1,206.52

78 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE43620 $1,929.6443621 $2,230.0943622 $2,264.8043631 $1,426.3543632 $1,997.9743633 $1,888.0643634 $2,080.7743635 $109.9143640 $1,159.5243641 $1,177.5943644 $1,702.2243645 $1,820.0843651 $643.5743652 $753.1343653 $567.6543752 $40.8643753 $21.6943754 $165.9643755 $158.0043756 $233.9343757 $325.7643761 $120.0443762 $226.3443763 $335.5343770 $1,106.3743771 $1,250.9943772 $933.1843773 $1,252.4443774 $944.3943775 $1,091.1843800 $915.4643810 $997.9043820 $1,320.4143825 $1,284.2543830 $692.3843831 $592.9643832 $1,021.0443840 $1,337.0443842 $1,202.9043843 $1,248.1043845 $1,917.7043846 $1,595.1943847 $1,766.9343848 $1,894.20

79 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE43850 $1,593.7543855 $1,612.1943860 $1,608.9343865 $1,674.0143870 $701.7843880 $1,566.2743886 $360.8343887 $324.6843888 $456.6544005 $1,077.4444010 $854.7244015 $138.8444020 $958.4944021 $961.7444025 $970.0644050 $920.5344055 $1,470.4644100 $108.8344110 $840.2644111 $973.3144120 $1,203.6344121 $237.9144125 $1,162.7744126 $2,414.8544127 $2,800.6344128 $238.6344130 $1,295.1044139 $118.5944140 $1,321.8644141 $1,800.5644143 $1,640.7544144 $1,744.1644145 $1,636.0544146 $2,094.5144147 $1,913.3644150 $1,846.4844151 $2,125.6044155 $2,060.1644156 $2,264.8044157 $2,156.6944158 $2,212.3744160 $1,224.6044180 $906.0644186 $641.40

80 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE44187 $1,096.6144188 $1,213.3944202 $1,363.8044203 $235.7444204 $1,519.6344205 $1,322.2244206 $1,727.5244207 $1,799.8444208 $1,965.4344210 $1,768.7444211 $2,168.6244212 $2,037.7444213 $185.4844227 $1,642.2044300 $829.7844310 $1,031.5244312 $588.9844314 $997.1844316 $1,390.1944320 $1,186.6344322 $995.0144340 $618.6344345 $1,040.2044346 $1,169.6444360 $146.4344361 $161.9844363 $195.6044364 $208.9844365 $185.8444366 $244.7744369 $250.9244370 $271.1744372 $243.6944373 $195.2444376 $289.9744377 $305.1544378 $393.3844379 $417.6044380 $177.8944381 $975.8544382 $279.4844384 $156.1944385 $199.5844386 $298.65

81 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE44388 $297.2044389 $393.3844390 $388.3144391 $689.4944392 $361.2044394 $416.5144401 $3,107.2344402 $266.8344403 $309.4944404 $383.6144405 $556.0844406 $234.6544407 $281.6544408 $236.8244500 $19.8944602 $1,387.3044603 $1,595.5644604 $1,042.7344605 $1,285.7044615 $1,059.0044620 $857.9844625 $1,006.5844626 $1,577.4844640 $1,381.8744650 $1,425.9844660 $1,330.5344661 $1,534.0944680 $1,054.6644700 $1,004.4144701 $166.3244705 $114.2544720 $268.6444721 $375.6644800 $758.1944820 $826.1644850 $739.0244900 $761.8044950 $632.3644955 $82.8044960 $861.5944970 $592.9645000 $424.8345005 $287.4445020 $569.45

82 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE45100 $299.7345108 $366.2645110 $1,829.8545111 $1,077.0845112 $1,856.9645113 $1,898.5445114 $1,781.4045116 $1,564.8245119 $1,928.5545120 $1,561.9345121 $1,699.3245123 $1,118.3045126 $2,773.5145130 $1,085.0445135 $1,308.8445136 $1,842.1445150 $411.4545160 $1,007.6645171 $603.8045172 $813.8745190 $700.3445300 $123.2945303 $948.3745305 $154.7545307 $177.5245308 $172.8245309 $178.9745315 $195.9645317 $194.5245320 $190.9045321 $101.6045327 $114.6145330 $174.2745331 $272.2545332 $261.7745333 $309.4945334 $551.3845335 $255.9845337 $116.7845338 $280.5745340 $453.3945341 $126.1845342 $173.1945346 $2,972.37

83 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE45347 $157.2845349 $202.1145350 $588.9845378 $324.3245379 $419.0545380 $418.3245381 $408.5645382 $721.3145384 $464.2445385 $437.4945386 $606.3345388 $3,129.6545389 $295.0345390 $339.5045391 $263.2145392 $310.5845393 $256.7145395 $1,965.7945397 $2,143.6845398 $743.3645400 $1,136.0245402 $1,506.6145500 $553.1845505 $595.1245520 $158.0045540 $1,053.5845541 $939.3345550 $1,457.0845560 $690.5845562 $1,113.6045563 $1,623.4045800 $1,240.8745805 $1,444.7945820 $1,246.2945825 $1,509.5045900 $201.3945905 $169.2145910 $191.9945915 $342.4045990 $106.3046020 $279.8546030 $142.4546040 $541.6146045 $434.59

84 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE46050 $212.2346060 $480.1546070 $260.6846080 $259.6046083 $185.4846200 $459.1846220 $219.8346221 $274.7846230 $285.2746250 $472.1946255 $515.5846257 $423.7546258 $464.6046260 $476.5346261 $522.4546262 $555.7146270 $518.8446275 $548.4846280 $474.3646285 $546.3146288 $551.0146320 $191.2646500 $292.8646505 $292.5046600 $96.9046601 $140.6546604 $659.1246606 $245.8646607 $197.7746608 $257.0746610 $245.1446611 $192.7146612 $296.8446614 $140.6546615 $152.9446700 $658.0446705 $552.4646706 $174.6346707 $487.7446710 $1,092.2746712 $2,193.2146715 $539.4446716 $1,199.2946730 $1,939.04

85 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE46735 $2,234.4346740 $2,117.2846742 $2,449.1946744 $3,441.3146746 $3,819.8646748 $4,143.4546750 $752.0446751 $649.7246753 $606.3346754 $319.2646760 $1,102.3946761 $919.0846900 $240.0746910 $262.1346916 $242.6146917 $439.2946922 $283.1046924 $539.0846930 $213.6846940 $239.3546942 $228.8746945 $321.4346946 $323.9646947 $381.0847000 $312.7547001 $101.9647010 $1,196.7647015 $1,146.8647100 $835.9247120 $2,296.6247122 $3,369.7247125 $3,026.2447130 $3,250.4147135 $5,286.7047140 $3,505.6747141 $4,192.2747142 $4,614.5647146 $318.5347147 $374.5747300 $1,115.7747350 $1,349.7047360 $1,844.6747361 $2,982.1347362 $1,428.15

86 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE47370 $1,229.6647371 $1,215.5647380 $1,421.6547381 $1,444.0647382 $4,702.7847383 $7,078.9447400 $2,116.9247420 $1,320.4147425 $1,345.7247460 $1,247.0147480 $867.7447490 $338.7847531 $355.4147532 $833.3947533 $1,266.1847534 $1,473.7147535 $1,022.8547536 $704.3147537 $413.6247538 $4,396.9147539 $4,871.2747540 $4,954.4347541 $1,212.3047542 $499.3147543 $479.4347544 $1,053.5847550 $161.6247552 $316.0047553 $312.3947554 $505.1047555 $331.1947556 $375.3047562 $648.6447563 $704.6847564 $1,096.2447570 $762.8947600 $1,051.7747605 $1,106.0147610 $1,233.2747612 $1,243.0447620 $1,345.7247700 $1,040.5647701 $1,690.6547711 $1,531.20

87 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE47712 $1,960.0147715 $1,306.6747720 $1,136.0247721 $1,334.1547740 $1,286.0647741 $1,450.9347760 $2,216.3547765 $2,975.9847780 $2,431.4847785 $3,190.0347800 $1,547.8347801 $1,098.0547802 $1,502.6447900 $1,348.9748000 $1,849.3748001 $2,257.9348020 $1,159.1548100 $877.5048102 $543.4248105 $2,798.4648120 $1,089.3748140 $1,539.5148145 $1,603.1548146 $1,850.0948148 $1,227.4948150 $3,063.8448152 $2,837.5148153 $3,051.5548154 $2,852.6948155 $1,788.6348400 $104.1348500 $1,134.9348510 $1,081.0648520 $1,073.1048540 $1,283.8948545 $1,320.0548547 $1,757.5348548 $1,633.8848552 $231.0448554 $2,525.1248556 $1,257.5049000 $759.6349002 $1,030.4449010 $915.10

88 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE49020 $1,568.4449040 $984.1649060 $1,083.5949062 $728.9049082 $202.4749083 $302.2649084 $106.3049180 $167.7649185 $1,091.1849203 $1,183.0249204 $1,510.2349205 $1,734.7649215 $2,191.0449220 $956.3249250 $582.8349255 $783.5049320 $323.2349321 $341.3149322 $366.9849323 $628.7549324 $381.8149325 $406.7549326 $184.3949327 $127.2749400 $138.4849402 $843.8849405 $859.4249406 $859.0649407 $696.0049411 $492.0849412 $80.9949418 $1,299.4449419 $437.4949421 $224.5349422 $218.7449423 $581.3949424 $156.1949425 $717.6949426 $608.8649427 $45.5649428 $424.8349429 $450.8649435 $116.0649436 $183.31

89 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE49440 $969.7049441 $1,098.4149442 $916.1949446 $933.9049450 $677.5649451 $736.4949452 $905.7049460 $737.2249465 $161.2549491 $782.4149492 $942.2249495 $403.8649496 $605.2549500 $403.1449501 $596.9349505 $513.7749507 $578.1349520 $622.6049521 $705.7649525 $565.4849540 $664.5449550 $567.6549553 $622.9649555 $589.7049557 $712.6349560 $726.7349561 $914.0249565 $757.1049566 $922.3349568 $262.1349570 $412.9049572 $509.4449580 $325.0449582 $464.6049585 $440.0249587 $470.0349590 $564.3949600 $716.9749605 $4,816.3149606 $1,113.2449610 $678.6449611 $598.7449650 $423.7549651 $551.01

90 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE49652 $732.5249653 $914.3849654 $831.9449655 $1,015.6249656 $901.7349657 $1,296.5549900 $807.7249904 $1,402.8549905 $347.4650010 $735.4150020 $1,026.1050040 $938.2450045 $944.0350060 $1,154.4550065 $1,223.8750070 $1,200.3750075 $1,474.4350080 $880.3950081 $1,292.9350100 $1,044.1850120 $961.3850125 $995.0150130 $1,045.6350135 $1,136.0250200 $548.4850205 $744.8150220 $1,053.2250225 $1,212.6750230 $1,294.0250234 $1,316.7950236 $1,483.1150240 $1,340.6650250 $1,231.4750280 $965.0050290 $910.0450320 $1,481.6650327 $212.6050328 $186.2050329 $177.5250340 $936.4450360 $2,381.5850365 $2,827.0250370 $1,190.6150380 $1,974.11

91 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE50382 $1,125.5350384 $898.1150385 $1,105.6450386 $728.9050387 $527.5150389 $341.3150390 $97.6250391 $124.0150396 $119.3150400 $1,172.8950405 $1,412.6150430 $521.0150431 $216.2150432 $844.6050433 $1,122.6450434 $886.1850435 $526.4350436 $153.6650437 $255.9850500 $1,264.0150520 $1,138.5550525 $1,443.3450526 $1,546.7550540 $1,159.8850541 $929.9350542 $1,181.2150543 $1,506.6150544 $1,259.6750545 $1,354.4050546 $1,215.9250547 $1,589.4150548 $1,361.9950551 $366.6250553 $391.9350555 $418.6850557 $425.9250561 $482.3250562 $587.5350570 $497.1450572 $538.0050574 $571.9850575 $722.0350576 $570.5450580 $614.29

92 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE50590 $741.1950592 $3,331.0350593 $4,524.1850600 $950.5450605 $981.6350606 $675.0350610 $955.6050620 $914.3850630 $904.2650650 $1,049.6050660 $1,156.9950684 $110.6450686 $141.3750688 $79.5450690 $101.9650693 $1,033.3350694 $1,138.5550695 $1,389.8350700 $937.5250705 $2,048.2350706 $985.2550715 $1,210.1350722 $1,017.0650725 $1,116.1350727 $514.8650728 $735.7750740 $1,201.8250750 $1,168.1950760 $1,131.3150770 $1,167.4750780 $1,113.9650782 $1,087.9350783 $1,141.8050785 $1,226.4050800 $937.8850810 $1,375.7350815 $1,238.3450820 $1,328.0050825 $1,677.6350830 $1,823.7050840 $1,244.8450845 $1,266.5450860 $957.0450900 $853.28

93 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE50920 $890.5250930 $1,115.7750940 $898.1150945 $983.8050947 $1,403.5750948 $1,289.3250951 $383.2550953 $405.3150955 $432.4250957 $436.4050961 $393.7450970 $374.9450972 $362.2850974 $478.3450976 $471.8350980 $360.4751020 $474.3651030 $477.9851040 $293.9551045 $494.2551050 $479.4351060 $589.7051065 $587.5351080 $414.7151100 $65.0851101 $134.8651102 $233.9351500 $645.3851520 $603.0851525 $869.1951530 $779.8851535 $789.6451550 $971.5151555 $1,279.1951565 $1,311.0151570 $1,490.7051575 $1,844.6751580 $1,916.9851585 $2,135.3651590 $1,954.5851595 $2,213.4651596 $2,381.5851597 $2,316.1451600 $199.94

94 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE51605 $39.0551610 $114.2551700 $75.5751701 $45.1951702 $62.9151703 $134.1451705 $94.7351710 $130.8851715 $321.0651720 $85.3351725 $203.5651725 26 $77.0151725 TC $126.5551726 $284.5551726 26 $86.7751726 TC $197.7751727 $336.2551727 26 $107.7451727 TC $228.5051728 $342.0351728 26 $105.9451728 TC $236.1051729 $365.1751729 26 $127.6351729 TC $237.5451736 $14.1051736 26 $8.3251736 TC $5.7851741 $14.4651741 26 $8.3251741 TC $6.1551784 $68.7051784 26 $37.9651784 TC $30.7351785 $323.5951785 26 $88.5851785 TC $235.0151792 $235.7451792 26 $56.0451792 TC $179.6951797 $141.7351797 26 $40.8651797 TC $100.8751798 $13.02

95 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE51800 $1,060.4551820 $1,098.0551840 $675.3951841 $787.4751845 $589.7051860 $748.0651865 $903.9051880 $471.8351900 $834.8451920 $773.7351925 $1,033.6951940 $1,661.7251960 $1,401.4051980 $722.7551990 $756.3851992 $839.1852000 $191.9952001 $399.1652005 $286.7252007 $470.7552010 $391.5752204 $386.1452214 $716.6152224 $748.4352234 $249.1152235 $291.4252240 $396.2752250 $241.8852260 $212.2352265 $378.9152270 $388.3152275 $514.5052276 $267.5552277 $326.8552281 $303.3552282 $340.2352283 $306.9652285 $306.2452287 $342.7652290 $247.3152300 $282.7452301 $292.8652305 $281.6552310 $272.25

96 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE52315 $446.5252317 $859.4252318 $478.7052320 $249.4852325 $323.9652327 $264.6652330 $549.9352332 $483.7652334 $185.4852341 $287.0852342 $312.3952343 $348.1852344 $373.4952345 $398.8052346 $451.2252351 $305.8852352 $358.3052353 $396.2752354 $421.9452355 $472.5652356 $420.8552400 $484.1352402 $269.7252441 $1,299.4452442 $978.7452450 $477.2652500 $496.0652601 $738.3052630 $407.1152640 $321.7952647 $1,653.0452648 $1,703.6652649 $835.2052700 $447.6153000 $150.4153010 $299.3753020 $97.9853025 $69.0653040 $398.4453060 $184.3953080 $426.6453085 $658.4053200 $159.0953210 $779.88

97 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE53215 $939.6953220 $458.4653230 $613.5653235 $641.4053240 $430.9853250 $401.6953260 $204.6453265 $223.8053270 $210.4353275 $265.7553400 $810.6153405 $884.7353410 $991.0353415 $1,143.9753420 $852.1953425 $948.7353430 $976.9353431 $1,168.1953440 $762.8953442 $793.9853444 $803.3853445 $763.9753446 $651.1753447 $818.9353448 $1,294.7453449 $620.4353450 $415.0753460 $464.6053500 $753.8553502 $493.1753505 $492.8053510 $640.3253515 $806.2753520 $565.4853600 $84.2453601 $80.9953605 $65.4453620 $134.1453621 $126.1853660 $70.5053661 $69.4253665 $39.0553850 $1,632.0753852 $1,578.92

98 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE53854 $1,870.3453855 $784.5853860 $1,898.9054000 $156.1954001 $192.7154015 $312.3954050 $134.5054055 $123.6554056 $142.8254057 $141.0154060 $187.2954065 $222.7254100 $199.9454105 $270.8154110 $632.7354111 $809.8954112 $950.1754115 $460.6254120 $640.6854125 $825.0854130 $1,208.6954135 $1,530.1154150 $155.8354160 $224.1754161 $199.9454162 $262.1354163 $222.0054164 $197.0554200 $111.0054205 $540.1754220 $210.7954230 $99.4354231 $143.5454235 $90.3954240 $104.4954240 26 $66.8954240 TC $37.6054250 $123.2954250 26 $111.0054250 TC $12.2954300 $653.7054304 $759.6354308 $725.2954312 $829.41

99 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE54316 $1,010.5554318 $720.5954322 $791.4554324 $981.2754326 $957.7754328 $951.2654332 $1,026.8254336 $1,205.0754340 $578.1354344 $959.9454348 $1,026.8254352 $1,434.3054360 $730.3554380 $810.2554385 $941.5054390 $1,257.1454400 $538.0054401 $667.0754405 $819.2954406 $740.4754408 $801.2154410 $872.0854411 $1,040.5654415 $536.5554416 $722.3954417 $910.0454420 $713.7254430 $649.3654435 $422.6654437 $683.7154438 $1,354.7654450 $69.7854500 $75.5754505 $212.9654512 $546.3154520 $330.8354522 $597.6654530 $513.0554535 $753.4954550 $498.9554560 $696.3654600 $459.9054620 $303.7154640 $484.49

100 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE54650 $721.3154660 $363.0054670 $412.5454680 $797.9654690 $665.6354692 $768.3154700 $215.4954800 $127.2754830 $378.1954840 $326.1354860 $425.5554861 $574.8854865 $364.4554900 $811.7054901 $1,070.9355000 $117.8755040 $342.7655041 $517.7555060 $386.1455100 $222.0055110 $392.6555120 $359.3955150 $498.2355175 $368.7955180 $697.4555200 $430.2555250 $379.2755300 $189.4655400 $505.1055500 $397.7155520 $449.4255530 $356.8655535 $436.7655540 $545.2355550 $434.9555600 $428.0855605 $529.6855650 $726.3755680 $349.9955700 $253.0955705 $269.3655706 $378.5555720 $458.4655725 $602.72

101 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE55801 $1,108.1855810 $1,328.7355812 $1,628.8255815 $1,781.4055821 $885.0955831 $957.7755840 $1,186.2755842 $1,186.9955845 $1,380.7955860 $886.9055862 $1,110.7155865 $1,346.8055866 $1,461.4255870 $177.5255873 $6,357.6455874 $3,560.2655875 $777.7155876 $143.5455920 $458.8256405 $114.2556420 $136.6756440 $180.0656441 $152.5856442 $47.0056501 $144.9856515 $236.1056605 $85.6956606 $37.9656620 $537.6456625 $639.6056630 $933.9056631 $1,178.6856632 $1,393.0856633 $1,210.8656634 $1,291.1256637 $1,499.3856640 $1,496.8556700 $189.0956740 $301.5456800 $242.2456805 $1,136.3856810 $262.1356820 $114.6156821 $152.58

102 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE57000 $190.9057010 $436.4057020 $97.2657022 $170.2957023 $309.1357061 $124.3857065 $206.0957100 $92.2057105 $147.1557106 $505.1057107 $1,441.8957109 $1,729.6957110 $887.6257111 $1,731.1457112 $1,855.5257120 $511.6057130 $187.6557135 $203.5657150 $48.8157155 $378.5557156 $210.7957160 $62.9157170 $65.0857180 $154.7557200 $309.8657210 $372.4057220 $324.6857230 $397.7157240 $595.1257250 $596.2157260 $761.0857265 $853.6457267 $252.7357268 $488.1057270 $801.5757280 $951.9857282 $510.8857283 $686.6057284 $816.0457285 $674.6757287 $700.3457288 $723.1257289 $762.5357291 $529.32

103 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE57292 $809.1757295 $482.6857296 $939.6957300 $572.7157305 $940.0557307 $1,039.1257308 $661.6557310 $477.2657311 $541.6157320 $544.1457330 $758.1957335 $1,147.2257400 $132.3357410 $106.3057415 $164.8757420 $120.4057421 $161.6257423 $911.8557425 $966.8157426 $846.7757452 $113.8957454 $156.5557455 $147.8857456 $138.8457460 $294.3157461 $330.8357500 $134.8657505 $112.8157510 $137.0357511 $156.1957513 $161.6257520 $321.0657522 $274.0657530 $351.8057531 $1,672.5757540 $770.8457545 $815.3157550 $410.0157555 $599.4657556 $567.6557558 $134.1457700 $321.7957720 $312.7557800 $65.08

104 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE58100 $92.9258110 $50.2658120 $268.6458140 $911.1358145 $550.2958146 $1,137.4658150 $1,006.2258152 $1,237.9758180 $952.3458200 $1,359.1058210 $1,824.7858240 $2,904.7658260 $820.7458262 $912.2158263 $979.8258267 $1,043.8258270 $875.6958275 $975.1258280 $1,039.4858285 $1,419.1258290 $1,137.4658291 $1,239.4258292 $1,293.6558293 $1,346.0858294 $1,201.1058300 $80.2758301 $95.0958340 $159.8158346 $470.3958353 $1,007.6658356 $1,872.8758400 $445.4458410 $797.2458520 $780.6058540 $899.1958541 $712.6358542 $813.8758543 $822.5458544 $890.8858545 $890.5258546 $1,104.9258548 $1,881.9158550 $870.9958552 $975.48

105 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE58553 $1,111.0758554 $1,305.9558555 $298.2958558 $1,397.0658559 $285.6358560 $312.3958561 $357.9458562 $367.7058563 $1,806.7158570 $780.6058571 $891.2458572 $1,019.2358573 $1,206.1658575 $1,877.2158600 $361.9258605 $327.9358611 $75.5758615 $243.6958660 $667.4458661 $643.5758662 $702.8758670 $362.2858671 $362.2858672 $723.4858673 $785.3058674 $804.8358700 $774.8258720 $736.1358740 $883.2958760 $802.3058770 $844.2458800 $329.0258805 $407.4858820 $317.0958822 $694.1958825 $689.1358900 $415.4358920 $695.2858925 $744.0958940 $529.3258943 $1,169.6458950 $1,129.1558951 $1,440.8158952 $1,633.88

106 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE58953 $2,011.7158954 $2,182.3658956 $1,368.1458957 $1,580.3758958 $1,748.1358960 $967.1758970 $225.6158976 $247.6759000 $121.8559001 $173.5559012 $195.9659015 $152.2259020 $69.4259020 26 $35.7959020 TC $33.6259025 $47.3659025 26 $28.5659025 TC $18.8059030 $109.1959050 $48.8159051 $40.4959070 $394.4659072 $506.1859074 $379.2759076 $506.1859100 $817.1259120 $778.8059121 $779.5259130 $907.8759135 $896.3059136 $859.7859140 $395.9159150 $754.9359151 $733.9659160 $212.9659200 $77.3759300 $198.1359320 $147.5259325 $234.2959350 $271.1759400 $2,057.2759409 $788.5659410 $1,011.6459412 $99.43

107 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE59414 $88.9459425 $452.3159426 $808.8159430 $192.3559510 $2,270.9559514 $885.4659515 $1,225.3259525 $468.2259610 $2,151.9959612 $883.6559614 $1,097.6959618 $2,299.1559620 $910.4059622 $1,261.4859812 $319.9859820 $385.7859821 $385.0659830 $433.1559840 $222.3659841 $382.1759850 $361.5659851 $390.1259852 $533.6659855 $406.3959856 $476.5359857 $533.3059866 $220.1959870 $480.1559871 $129.4460000 $172.1060100 $113.1760200 $656.5960210 $699.6160212 $997.5460220 $700.3460225 $921.9760240 $908.2360252 $1,304.5060254 $1,655.5760260 $1,081.4260270 $1,350.4260271 $1,046.3560280 $443.6360281 $587.17

108 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE60300 $116.4260500 $954.1560502 $1,273.4160505 $1,379.3460512 $239.3560520 $1,026.1060521 $1,098.7760522 $1,339.2160540 $1,058.2860545 $1,210.5060600 $1,345.0060605 $1,611.1060650 $1,180.1361000 $107.0261001 $104.1361020 $97.9861026 $104.8561050 $86.4161055 $123.6561070 $56.7661105 $450.8661107 $300.4561108 $869.5561120 $722.7561140 $1,221.3461150 $1,308.1261151 $962.1161154 $1,228.9461156 $1,201.1061210 $353.2461215 $497.5061250 $836.6561253 $956.3261304 $1,585.7961305 $1,930.3661312 $1,999.7861313 $1,911.2061314 $1,757.1761315 $1,987.8561316 $84.6061320 $1,828.4061321 $2,035.5761322 $2,290.4761323 $2,291.92

109 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE61330 $1,723.1961333 $1,953.5061340 $1,375.7361343 $2,108.2461345 $1,961.8161450 $1,843.2261458 $1,936.1461460 $2,026.1761500 $1,282.8161501 $1,119.0261510 $2,111.1461512 $2,456.0661514 $1,840.6961516 $1,795.5061517 $84.2461518 $2,660.7161519 $2,840.7661520 $3,632.9361521 $3,064.9361522 $2,082.2161524 $2,001.2261526 $3,281.5061530 $2,970.9261531 $1,171.8161533 $1,464.3161534 $1,572.4261535 $966.4461536 $2,471.6161537 $2,372.1861538 $2,563.4561539 $2,278.9061540 $2,082.2161541 $2,062.6961543 $2,052.5661544 $1,835.2761545 $3,055.1761546 $2,215.9961548 $1,523.2461550 $1,098.7761552 $1,432.4961556 $1,647.2661557 $1,625.9361558 $1,815.0261559 $2,234.43

110 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE61563 $1,896.3761564 $2,323.3761566 $2,141.8761567 $2,421.7261570 $1,795.1461571 $1,896.7361575 $2,411.9561576 $4,031.3761580 $2,427.5061581 $2,659.9861582 $2,966.2261583 $2,801.7161584 $2,782.1961585 $3,142.3061586 $2,375.0761590 $3,029.4961591 $3,047.2161592 $3,074.6961595 $2,328.4361596 $2,440.1561597 $2,836.0661598 $2,752.5461600 $2,115.4861601 $2,340.7361605 $2,159.5961606 $2,857.7561607 $2,637.9361608 $3,160.7461611 $450.8661613 $3,188.2261615 $2,719.2861616 $3,239.5661618 $1,254.6161619 $1,398.8761623 $554.9961624 $1,125.1761626 $874.2561630 $1,355.8461635 $1,433.5861640 $478.3461641 $168.1261642 $336.2561645 $819.2961650 $540.53

111 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE61651 $234.2961680 $2,174.0561682 $4,021.6161684 $2,728.6861686 $4,403.0561690 $2,095.5961692 $3,540.7461697 $4,084.8861698 $4,524.9061700 $3,293.7961702 $3,868.3161703 $1,295.8261705 $2,449.1961708 $2,458.2361710 $2,074.6261711 $2,490.4161720 $1,228.2161735 $1,537.7161750 $1,361.2761751 $1,334.8761760 $1,513.8461770 $1,567.3561781 $226.3461782 $173.5561783 $224.1761790 $853.2861791 $1,088.2961796 $980.9161797 $210.7961798 $1,333.7961799 $291.7861800 $148.2461850 $938.2461860 $1,505.5361863 $1,450.2161864 $271.8961867 $2,195.0261868 $479.0661870 $1,145.0561880 $556.8061885 $503.6561886 $830.5061888 $383.9762000 $997.90

112 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE62005 $1,214.8362010 $1,474.8062100 $1,542.7762115 $1,620.8662117 $1,894.9362120 $2,069.5662121 $1,558.3162140 $998.2662141 $1,104.5662142 $858.3462143 $1,006.5862145 $1,356.9362146 $1,147.5962147 $1,391.6462148 $121.1262160 $182.2362161 $1,455.9962162 $1,820.0862163 $1,156.2662164 $2,011.3562165 $1,496.8562180 $1,545.6662190 $897.0362192 $948.3762194 $474.0062200 $1,326.5662201 $1,169.2862220 $970.7862223 $1,010.5562225 $513.7762230 $814.5962252 $79.9062252 26 $44.1162252 TC $35.7962256 $585.0062258 $1,078.1762263 $612.4862264 $435.6862267 $261.0462268 $259.6062269 $269.7262270 $149.6962272 $196.3362273 $174.99

113 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE62280 $333.7262281 $246.9462282 $308.0562284 $199.2262287 $585.3662290 $343.4862291 $331.5562292 $583.1962294 $918.3662302 $254.5462303 $260.3262304 $251.2862305 $272.9862320 $166.6862321 $257.4362322 $155.4762323 $254.5462324 $146.4362325 $238.2762326 $152.2262327 $239.3562350 $396.6362351 $843.8862355 $267.1962360 $313.4762361 $416.5162362 $379.2762365 $292.8662367 $40.4962368 $55.6862369 $119.6862370 $124.0163001 $1,200.3763003 $1,201.4663005 $1,153.0163011 $1,074.9163012 $1,161.6963015 $1,435.0263016 $1,478.0563017 $1,222.7963020 $1,132.4063030 $951.2663035 $186.2063040 $1,358.73

114 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE63042 $1,271.2463045 $1,249.9163046 $1,197.1263047 $1,078.1763048 $205.7363050 $1,463.9563051 $1,671.1263055 $1,577.1263056 $1,451.6663057 $310.5863064 $1,727.5263066 $196.6963075 $1,320.4163076 $239.7163077 $1,485.2863078 $197.7763081 $1,714.1563082 $258.8863085 $1,875.7663086 $186.2063087 $2,352.6663088 $252.0163090 $1,931.0863091 $174.9963101 $2,257.2163102 $2,219.2463103 $285.9963170 $1,531.5663172 $1,342.8363173 $1,654.4963180 $1,397.7863182 $1,499.7463185 $1,124.8163190 $1,238.7063191 $1,334.1563194 $1,544.5863195 $1,483.1163196 $1,720.2963197 $1,571.6963198 $2,018.9463199 $2,114.7563200 $1,479.5063250 $2,823.4163251 $2,924.28

115 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE63252 $2,913.8063265 $1,612.5563266 $1,665.7063267 $1,332.3463268 $1,373.2063270 $1,990.3863271 $1,991.4663272 $1,829.1263273 $1,793.3363275 $1,740.5463276 $1,729.6963277 $1,512.4063278 $1,528.3163280 $2,038.8363281 $2,017.1363282 $1,903.9663283 $1,824.7863285 $2,518.2563286 $2,484.2763287 $2,632.1463290 $2,673.3663295 $317.8163300 $1,779.9563301 $2,114.0363302 $2,087.2763303 $2,107.1663304 $2,234.7963305 $2,415.2163306 $2,329.1663307 $2,323.3763308 $312.0263600 $1,055.3963610 $560.0563620 $1,083.2363621 $242.9763650 $1,651.2463655 $810.6163661 $619.3563662 $820.3863663 $831.5863664 $849.6663685 $358.3063688 $368.7963700 $1,256.41

116 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE63702 $1,378.6263704 $1,563.0263706 $1,732.5963707 $907.8763709 $1,080.3463710 $1,065.1563740 $942.5863741 $660.5763744 $651.8963746 $581.7564400 $136.3164402 $148.9664405 $82.4464408 $119.3164410 $154.3964413 $126.5564415 $120.0464416 $80.2764417 $133.7864418 $95.8164420 $112.0864421 $159.0964425 $139.2064430 $147.5264435 $141.7364445 $138.1264446 $80.2764447 $122.9364448 $71.9564449 $85.3364450 $78.1064455 $48.0964461 $141.0164462 $78.1064463 $182.9564479 $248.0364480 $121.4864483 $230.3164484 $99.4364486 $111.0064487 $160.1764488 $136.3164489 $238.2764490 $192.35

117 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE64491 $95.0964492 $95.8164493 $175.3664494 $88.5864495 $88.5864505 $117.5164510 $134.8664517 $193.4364520 $205.7364530 $205.0064553 $1,752.1164555 $1,589.7764561 $745.8964566 $129.8064568 $622.2464569 $741.9264570 $709.7464575 $329.3864580 $303.7164581 $666.7164585 $249.8464590 $269.3664595 $245.1464600 $434.2364605 $593.3264610 $758.1964611 $118.2364612 $133.4164615 $144.2664616 $128.7164617 $162.3464620 $209.7064630 $237.9164632 $87.1464633 $424.8364634 $191.2664635 $420.1364636 $173.9164640 $137.7564642 $143.9064643 $91.8464644 $167.4064645 $114.9864646 $150.05

118 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE64647 $174.6364650 $79.1864653 $96.1764680 $323.9664681 $575.2464702 $505.1064704 $325.4064708 $501.1264712 $581.0264713 $771.5664714 $720.5964716 $522.8164718 $592.5964719 $402.0564721 $433.5164722 $356.1364726 $275.8764727 $181.5064732 $432.4264734 $488.4664736 $373.8564738 $465.3364740 $488.8364742 $501.8464744 $479.4364746 $423.3864755 $896.6664760 $505.8264763 $503.2964766 $613.5664771 $592.9664772 $562.2264774 $407.4864776 $390.8464778 $181.1464782 $462.4364783 $216.2164784 $725.2964786 $983.4464787 $240.4464788 $399.8864790 $825.8064792 $1,068.0464795 $190.18

119 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE64802 $808.8164804 $1,135.2964809 $1,034.7864818 $776.9964820 $716.2564821 $692.0264822 $692.0264823 $785.6764831 $688.4164832 $335.1664834 $741.5664835 $809.8964836 $810.2564837 $364.0964840 $957.7764856 $1,009.8364857 $1,052.1364858 $1,171.0964859 $246.2264861 $1,465.3964862 $1,358.7364864 $865.5764865 $1,098.4164866 $1,282.4564868 $1,007.6664872 $115.7064874 $173.1964876 $196.3364885 $1,117.2164886 $1,294.0264890 $1,073.8364891 $1,140.3564892 $1,040.2064893 $1,115.4164895 $1,317.1664896 $1,424.5464897 $1,257.1464898 $1,364.1664901 $594.4064902 $688.4164905 $1,017.7964907 $1,295.4664910 $797.9664911 $1,021.40

120 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE64912 $777.7164913 $155.4765091 $656.5965093 $649.7265101 $762.5365103 $793.6265105 $873.1665110 $1,248.4665112 $1,445.1565114 $1,513.8465125 $467.1365130 $755.2965135 $765.7865140 $831.9465150 $599.8265155 $869.9165175 $680.0965205 $47.0065210 $57.1365220 $59.6665222 $69.0665235 $721.6765260 $975.8565265 $1,095.8865270 $279.4865272 $520.6465273 $386.1465275 $590.7965280 $679.7365285 $1,122.6465286 $717.6965290 $496.7865400 $693.8365410 $146.7965420 $534.3865426 $671.0565430 $117.8765435 $82.8065436 $393.7465450 $331.9165600 $406.3965710 $1,130.9565730 $1,251.3565750 $1,256.78

121 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE65755 $1,250.2765756 $1,196.4065770 $1,410.0865772 $459.5465775 $563.6765778 $1,448.0465779 $1,244.4865780 $675.7565781 $1,348.9765782 $1,162.7765785 $2,508.4965800 $121.8565810 $471.4765815 $652.9765820 $767.9565850 $849.6665855 $249.8465860 $314.1965865 $479.7965870 $598.0265875 $638.5165880 $671.7765900 $983.8065920 $798.3265930 $643.9366020 $194.1666030 $174.2766130 $711.9166150 $889.0766155 $888.3566160 $1,001.1566170 $1,108.5466172 $1,207.6066174 $958.4966175 $1,003.6966179 $1,091.9166180 $1,151.5666183 $1,043.0966184 $796.1566185 $856.8966225 $942.2266250 $765.7866500 $364.4566505 $398.80

122 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE66600 $853.2866605 $1,079.9766625 $434.5966630 $575.9666635 $581.7566680 $524.2666682 $656.2366700 $458.8266710 $449.4266711 $651.5366720 $470.0366740 $445.8066761 $303.7166762 $484.1366770 $537.6466820 $409.6566821 $336.6166825 $779.1666830 $716.9766840 $704.6866850 $801.5766852 $853.6466920 $761.8066930 $865.9366940 $791.4566982 $802.6666983 $752.0466984 $646.4766985 $778.4366986 $919.0866990 $90.7567005 $478.7067010 $549.2167015 $590.7967025 $744.0967027 $861.9567028 $102.6867030 $542.7067031 $396.2767036 $911.4967039 $975.8567040 $1,054.3067041 $1,164.2267042 $1,164.22

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE67043 $1,228.5767101 $335.5367105 $301.5467107 $1,144.6967108 $1,212.3067110 $894.8667113 $1,353.3167115 $505.8267120 $673.5867121 $918.3667141 $532.2167145 $535.4767208 $608.1467210 $524.6267218 $1,399.2367220 $541.2567221 $287.8067225 $30.0167227 $297.2067228 $346.3767229 $1,178.6867250 $805.9167255 $692.0267311 $603.8067312 $719.8667314 $680.0967316 $809.1767318 $710.8267320 $325.0467331 $308.4167332 $334.4467334 $304.4367335 $149.3267340 $361.2067343 $659.4867345 $244.7767346 $195.2467400 $954.8767405 $813.1467412 $878.9567413 $879.6767414 $1,355.1267415 $105.2167420 $1,642.92

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE67430 $1,281.0067440 $1,239.4267445 $1,433.2267450 $1,288.2367500 $71.5967505 $84.6067515 $80.2767550 $989.9567560 $1,014.8967570 $1,191.3367700 $280.9367710 $235.7467715 $253.4567800 $129.8067801 $165.5967805 $205.3667808 $371.6867810 $178.2567820 $33.2667825 $132.3367830 $274.0667835 $443.9967840 $283.4667850 $218.7467875 $177.5267880 $468.5867882 $574.8867900 $651.1767901 $782.4167902 $729.6267903 $605.6167904 $746.6267906 $513.7767908 $505.8267909 $547.7667911 $568.0167912 $908.6067914 $484.4967915 $305.5267916 $609.2367917 $620.0767921 $475.8167922 $300.0967923 $609.59

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE67924 $649.0067930 $372.4067935 $603.8067938 $258.5167950 $584.2867961 $587.8967966 $782.0567971 $731.0767973 $940.4167974 $938.6067975 $691.6668020 $122.5768040 $63.6368100 $177.8968110 $235.0168115 $325.0468130 $553.5568135 $160.1768200 $41.9468320 $744.4568325 $665.2768326 $652.9768328 $715.1668330 $621.8868335 $655.5068340 $573.4368360 $545.9568362 $664.5468371 $418.3268400 $295.7568420 $332.6368440 $104.4968500 $992.4868505 $987.7868510 $458.0968520 $697.0868525 $265.7568530 $438.9368540 $944.0368550 $1,157.7168700 $611.0368705 $250.2068720 $768.3168745 $772.29

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE68750 $800.1368760 $211.8768761 $151.1368770 $636.3468801 $92.2068810 $159.8168811 $137.7568815 $401.6968816 $738.6668840 $131.2568850 $63.6369000 $188.0169005 $216.2169020 $233.9369100 $99.0769105 $142.0969110 $460.9969120 $400.2469140 $885.0969145 $396.2769150 $1,032.2569155 $1,645.4569200 $82.0769205 $99.0769209 $14.4669210 $47.3669220 $80.6369222 $217.6669300 $641.4069310 $1,095.5269320 $1,533.7369420 $190.5469421 $148.2469424 $129.0869433 $201.0369436 $158.3669440 $688.4169450 $545.9569501 $723.4869502 $959.2169505 $1,208.3369511 $1,237.2569530 $1,655.2169535 $2,677.34

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE69540 $209.3469550 $1,045.2669552 $1,570.2569554 $2,512.1069601 $1,034.7869602 $1,086.1269603 $1,265.0969604 $1,110.7169605 $1,563.0269610 $381.0869620 $702.5169631 $884.7369632 $1,077.0869633 $1,044.5469635 $1,244.1269636 $1,385.4969637 $1,401.7669641 $1,040.2069642 $1,335.6069643 $1,220.6269644 $1,483.8369645 $1,457.8069646 $1,550.0069650 $802.3069660 $924.1469661 $1,203.9969662 $1,153.3769666 $807.0069667 $809.5369670 $941.8669676 $830.5069700 $677.9269711 $852.9269714 $1,066.2369715 $1,314.9969717 $1,117.5869718 $1,328.3669720 $1,194.9569725 $1,870.3469740 $1,162.0569745 $1,237.6169801 $205.7369805 $1,043.0969806 $932.82

128 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE69905 $915.8369910 $1,005.1369915 $1,522.1669930 $1,218.0969950 $1,763.6869955 $1,965.0769960 $1,904.6969970 $2,129.9469990 $208.9870010 $60.7470015 $155.8370015 26 $60.0270015 TC $95.8170030 $29.6570030 26 $8.3270030 TC $21.3370100 $34.7170100 26 $9.0470100 TC $25.6770110 $40.4970110 26 $12.6570110 TC $27.8470120 $34.7170120 26 $9.7670120 TC $25.6770130 $57.8570130 26 $17.3570130 TC $40.4970134 $54.2370134 26 $17.7270134 TC $36.5270140 $30.7370140 26 $10.1270140 TC $20.6170150 $44.1170150 26 $13.3870150 TC $30.7370160 $34.7170160 26 $8.6870160 TC $26.0370170 26 $15.1970190 $36.8870190 26 $10.8570190 TC $26.03

129 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE70200 $44.4770200 26 $14.1070200 TC $30.3770210 $31.8270210 26 $8.6870210 TC $23.1470220 $39.4170220 26 $12.6570220 TC $26.7670240 $31.8270240 26 $10.1270240 TC $22.0670250 $38.3370250 26 $12.6570250 TC $25.6770260 $48.0970260 26 $17.7270260 TC $30.3770300 $14.1070300 26 $5.4270300 TC $8.6870310 $37.9670310 26 $7.5970310 TC $30.3770320 $54.9670320 26 $12.2970320 TC $42.6670328 $31.8270328 26 $9.0470328 TC $22.7870330 $49.9070330 26 $12.2970330 TC $37.6070332 $77.0170332 26 $27.1270332 TC $49.9070336 $305.1570336 26 $74.1270336 TC $231.0470350 $18.8070350 26 $9.7670350 TC $9.0470355 $19.8970355 26 $10.85

130 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE70355 TC $9.0470360 $30.3770360 26 $8.3270360 TC $22.0670370 $77.3770370 26 $14.8270370 TC $62.5570371 $99.0770371 26 $42.6670371 TC $56.4070380 $33.9970380 26 $8.3270380 TC $25.6770390 $104.4970390 26 $19.1670390 TC $85.3370450 $116.7870450 26 $42.6670450 TC $74.1270460 $165.2370460 26 $57.1370460 TC $108.1170470 $193.4370470 26 $64.0070470 TC $129.4470480 $177.5270480 26 $64.3670480 TC $113.1770481 $272.2570481 26 $69.7870481 TC $202.4770482 $275.1570482 26 $73.0370482 TC $202.1170486 $140.6570486 26 $43.0370486 TC $97.6270487 $169.2170487 26 $56.7670487 TC $112.4470488 $206.0970488 26 $64.0070488 TC $142.0970490 $165.96

131 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE70490 26 $64.3670490 TC $101.6070491 $205.0070491 26 $69.7870491 TC $135.2270492 $246.9470492 26 $81.3570492 TC $165.5970496 $290.3370496 26 $88.2270496 TC $202.1170498 $290.3370498 26 $88.2270498 TC $202.1170540 $269.0070540 26 $67.9770540 TC $201.0370542 $319.6270542 26 $82.0770542 TC $237.5470543 $401.6970543 26 $108.1170543 TC $293.5970544 $282.0270544 26 $60.7470544 TC $221.2770545 $279.8570545 26 $60.7470545 TC $219.1070546 $413.9870546 26 $74.4870546 TC $339.5070547 $283.1070547 26 $60.7470547 TC $222.3670548 $311.3070548 26 $75.9370548 TC $235.3770549 $432.4270549 26 $90.7570549 TC $341.6770551 $229.2370551 26 $74.8470551 TC $154.39

132 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE70552 $318.1770552 26 $90.0370552 TC $228.1470553 $375.3070553 26 $115.3470553 TC $259.9670554 $445.8070554 26 $106.3070554 TC $339.5070555 26 $127.2770557 26 $158.0070558 26 $173.9170559 26 $164.5171045 $24.9571045 26 $9.0471045 TC $15.9171046 $31.8271046 26 $11.2171046 TC $20.9771047 $40.1371047 26 $14.1071047 TC $26.0371048 $43.3971048 26 $16.2771048 TC $27.1271100 $34.7171100 26 $11.2171100 TC $23.5071101 $39.7771101 26 $13.7471101 TC $26.0371110 $41.5871110 26 $14.8271110 TC $26.7671111 $49.5371111 26 $16.6371111 TC $32.9071120 $31.4671120 26 $10.4971120 TC $21.3371130 $37.6071130 26 $11.2171130 TC $26.7671250 $160.17

133 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE71250 26 $58.5771250 TC $101.6071260 $198.5071260 26 $62.5571260 TC $135.9571270 $235.7471270 26 $69.7871270 TC $165.9671275 $293.9571275 26 $91.8471275 TC $202.1171550 $304.4371550 26 $73.4071550 TC $231.0471551 $454.4871551 26 $87.1471551 TC $367.3471552 $500.7671552 26 $113.8971552 TC $386.8771555 $396.9971555 26 $90.3971555 TC $306.6072020 $23.1472020 26 $7.5972020 TC $15.5572040 $36.8872040 26 $11.2172040 TC $25.6772050 $50.9872050 26 $15.9172050 TC $35.0772052 $60.7472052 26 $18.4472052 TC $42.3072070 $34.3572070 26 $11.2172070 TC $23.1472072 $36.5272072 26 $11.2172072 TC $25.6772074 $40.1372074 26 $11.2172074 TC $29.29

134 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE72080 $33.9972080 26 $11.2172080 TC $22.7872081 $40.8672081 26 $13.7472081 TC $27.1272082 $65.8072082 26 $16.2772082 TC $49.5372083 $77.7372083 26 $18.4472083 TC $59.3072084 $90.3972084 26 $20.9772084 TC $69.4272100 $36.8872100 26 $11.2172100 TC $25.6772110 $51.7072110 26 $15.9172110 TC $35.7972114 $58.9372114 26 $16.6372114 TC $42.3072120 $43.3972120 26 $11.2172120 TC $32.1872125 $166.6872125 26 $53.8772125 TC $112.8172126 $229.9572126 26 $61.4672126 TC $168.4972127 $266.1172127 26 $63.6372127 TC $202.4772128 $163.4272128 26 $50.6272128 TC $112.8172129 $231.4072129 26 $61.4672129 TC $169.9372130 $266.1172130 26 $63.63

135 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE72130 TC $202.4772131 $163.4272131 26 $50.6272131 TC $112.8172132 $230.3172132 26 $61.4672132 TC $168.8572133 $266.4772133 26 $64.0072133 TC $202.4772141 $223.0872141 26 $74.8472141 TC $148.2472142 $324.3272142 26 $90.3972142 TC $233.9372146 $223.4472146 26 $74.8472146 TC $148.6072147 $322.5172147 26 $90.0372147 TC $232.4872148 $223.4472148 26 $74.8472148 TC $148.6072149 $320.3472149 26 $90.3972149 TC $229.9572156 $377.8372156 26 $115.3472156 TC $262.4972157 $378.9172157 26 $115.3472157 TC $263.5872158 $377.1072158 26 $115.3472158 TC $261.7772159 $411.0972159 26 $90.7572159 TC $320.3472170 $33.2672170 26 $8.6872170 TC $24.5972190 $40.13

136 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE72190 26 $10.8572190 TC $29.2972191 $292.8672191 26 $90.7572191 TC $202.1172192 $147.1572192 26 $54.9672192 TC $92.2072193 $236.8272193 26 $58.5772193 TC $178.2572194 $263.5872194 26 $61.1072194 TC $202.4772195 $274.0672195 26 $73.7672195 TC $200.3072196 $319.6272196 26 $87.5072196 TC $232.1272197 $403.8672197 26 $111.0072197 TC $292.8672198 $398.8072198 26 $89.6772198 TC $309.1372200 $31.0972200 26 $8.6872200 TC $22.4272202 $35.0772202 26 $9.4072202 TC $25.6772220 $30.7372220 26 $8.6872220 TC $22.0672240 $105.2172240 26 $45.5672240 TC $59.6672255 $106.6672255 26 $47.3672255 TC $59.3072265 $98.3472265 26 $40.8672265 TC $57.49

137 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE72270 $136.6772270 26 $67.9772270 TC $68.7072275 $125.1072275 26 $39.4172275 TC $85.6972285 $118.9572285 26 $60.0272285 TC $58.9372295 $103.7772295 26 $43.3972295 TC $60.3873000 $29.2973000 26 $8.3273000 TC $20.9773010 $32.1873010 26 $9.4073010 TC $23.1473020 $23.8673020 26 $7.9573020 TC $15.9173030 $30.3773030 26 $9.7673030 TC $20.9773040 $112.0873040 26 $27.4873040 TC $84.6073050 $37.6073050 26 $10.4973050 TC $27.1273060 $30.3773060 26 $8.3273060 TC $22.0673070 $27.1273070 26 $7.9573070 TC $19.1673080 $30.0173080 26 $8.6873080 TC $21.3373085 $107.3873085 26 $28.9273085 TC $78.4673090 $28.2073090 26 $8.32

138 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE73090 TC $19.8973092 $28.9273092 26 $7.9573092 TC $20.9773100 $32.1873100 26 $8.3273100 TC $23.8673110 $36.8873110 26 $8.6873110 TC $28.2073115 $119.6873115 26 $28.5673115 TC $91.1173120 $29.2973120 26 $8.3273120 TC $20.9773130 $33.6273130 26 $8.6873130 TC $24.9573140 $33.9973140 26 $6.8773140 TC $27.1273200 $163.4273200 26 $50.6273200 TC $112.8173201 $225.6173201 26 $58.5773201 TC $167.0473202 $263.9473202 26 $61.4673202 TC $202.4773206 $292.5073206 26 $90.3973206 TC $202.1173218 $299.3773218 26 $68.3373218 TC $231.0473219 $399.8873219 26 $82.0773219 TC $317.8173220 $494.9773220 26 $108.4773220 TC $386.5173221 $235.74

139 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE73221 26 $68.7073221 TC $167.0473222 $376.7473222 26 $82.4473222 TC $294.3173223 $467.4973223 26 $108.8373223 TC $358.6773225 $393.7473225 26 $85.3373225 TC $308.4173501 $31.0973501 26 $9.7673501 TC $21.6973502 $43.3973502 26 $11.2173502 TC $32.1873503 $54.2373503 26 $14.1073503 TC $40.1373521 $38.6973521 26 $11.2173521 TC $27.4873522 $50.6273522 26 $15.1973522 TC $35.4373523 $59.3073523 26 $16.2773523 TC $43.0373525 $113.8973525 26 $28.9273525 TC $84.9773551 $28.5673551 26 $8.3273551 TC $20.2573552 $33.6273552 26 $9.0473552 TC $24.5973560 $32.5473560 26 $8.3273560 TC $24.2273562 $37.6073562 26 $9.7673562 TC $28.20

140 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE73564 $41.9473564 26 $11.2173564 TC $30.7373565 $37.6073565 26 $9.0473565 TC $28.9273580 $128.7173580 26 $28.5673580 TC $100.1573590 $29.6573590 26 $7.9573590 TC $21.6973592 $28.9273592 26 $7.9573592 TC $20.9773600 $31.0973600 26 $8.3273600 TC $22.7873610 $33.6273610 26 $8.6873610 TC $24.9573615 $119.6873615 26 $28.9273615 TC $90.7573620 $27.1273620 26 $7.5973620 TC $19.5273630 $31.4673630 26 $8.3273630 TC $23.1473650 $27.1273650 26 $7.9573650 TC $19.1673660 $28.9273660 26 $6.5173660 TC $22.4273700 $163.4273700 26 $50.6273700 TC $112.8173701 $228.5073701 26 $58.5773701 TC $169.9373702 $263.5873702 26 $61.10

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE73702 TC $202.4773706 $297.2073706 26 $95.0973706 TC $202.1173718 $265.7573718 26 $67.9773718 TC $197.7773719 $314.1973719 26 $82.0773719 TC $232.1273720 $403.1473720 26 $108.4773720 TC $294.6773721 $235.7473721 26 $68.7073721 TC $167.0473722 $378.5573722 26 $82.4473722 TC $296.1273723 $466.4173723 26 $108.4773723 TC $357.9473725 $399.1673725 26 $90.3973725 TC $308.7774018 $28.5674018 26 $9.0474018 TC $19.5274019 $35.0774019 26 $11.5774019 TC $23.5074021 $40.4974021 26 $13.7474021 TC $26.7674022 $47.0074022 26 $16.2774022 TC $30.7374150 $151.1374150 26 $60.0274150 TC $91.1174160 $241.5274160 26 $64.0074160 TC $177.5274170 $272.98

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE74170 26 $70.5074170 TC $202.4774174 $400.9774174 26 $109.9174174 TC $291.0574175 $293.2274175 26 $91.1174175 TC $202.1174176 $202.4774176 26 $87.8674176 TC $114.6174177 $323.2374177 26 $92.2074177 TC $231.0474178 $364.8174178 26 $101.2474178 TC $263.5874181 $247.3174181 26 $73.7674181 TC $173.5574182 $363.3774182 26 $87.5074182 TC $275.8774183 $404.2274183 26 $111.0074183 TC $293.2274185 $400.2474185 26 $90.0374185 TC $310.2274190 26 $23.5074210 $89.3074210 26 $29.6574210 TC $59.6674220 $97.9874220 26 $33.9974220 TC $64.0074230 $129.0874230 26 $26.7674230 TC $102.3274235 26 $60.3874240 $124.0174240 26 $35.0774240 TC $88.9474241 $129.08

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE74241 26 $34.7174241 TC $94.3774245 $188.3774245 26 $45.5674245 TC $142.8274246 $138.1274246 26 $34.7174246 TC $103.4174247 $155.4774247 26 $34.7174247 TC $120.7674249 $202.1174249 26 $45.5674249 TC $156.5574250 $114.2574250 26 $23.5074250 TC $90.7574251 $266.1174251 26 $34.7174251 TC $231.4074260 $138.4874260 26 $25.3174260 TC $113.1774261 $234.6574261 26 $121.4874261 TC $113.1774262 $329.0274262 26 $126.5574262 TC $202.4774263 $768.6774263 26 $115.3474263 TC $653.3474270 $163.4274270 26 $34.7174270 TC $128.7174280 $230.6774280 26 $49.9074280 TC $180.7874283 $236.8274283 26 $104.1374283 TC $132.6974290 $77.3774290 26 $16.2774290 TC $61.10

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE74300 26 $18.4474301 26 $10.8574328 26 $35.7974329 26 $36.1674330 26 $45.9274340 26 $27.4874355 26 $38.3374360 26 $28.2074363 26 $43.3974400 $120.7674400 26 $24.5974400 TC $96.1774410 $122.5774410 26 $24.2274410 TC $98.3474415 $146.4374415 26 $24.5974415 TC $121.8574420 $72.6774420 26 $26.0374420 TC $46.6474425 26 $17.7274430 $39.7774430 26 $16.2774430 TC $23.5074440 $87.8674440 26 $18.4474440 TC $69.4274445 26 $56.4074450 26 $16.6374455 $91.8474455 26 $16.6374455 TC $75.2074470 26 $26.7674485 $108.4774485 26 $40.4974485 TC $67.9774710 $38.6974710 26 $17.3574710 TC $21.3374712 $382.5374712 26 $151.4974712 TC $231.0474713 $236.46

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE74713 26 $93.6474713 TC $142.8274740 $83.5274740 26 $19.1674740 TC $64.3674742 26 $31.0974775 26 $31.4675557 $329.0275557 26 $116.7875557 TC $212.2375559 $459.5475559 26 $144.6275559 TC $314.9275561 $432.7875561 26 $129.4475561 TC $303.3575563 $513.4175563 26 $148.6075563 TC $364.8175565 $54.6075565 26 $12.6575565 TC $41.9475571 $91.4775571 26 $28.9275571 TC $62.5575572 $270.0875572 26 $87.8675572 TC $182.2375573 $329.7475573 26 $127.6375573 TC $202.1175574 $321.7975574 26 $119.3175574 TC $202.4775600 $202.4775600 26 $23.8675600 TC $178.6175605 $134.8675605 26 $55.3275605 TC $79.5475625 $132.3375625 26 $54.6075625 TC $77.7375630 $165.96

146 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE75630 26 $86.7775630 TC $79.1875635 $321.7975635 26 $119.3175635 TC $202.4775705 $251.2875705 26 $113.8975705 TC $137.3975710 $167.0475710 26 $84.6075710 TC $82.4475716 $178.6175716 26 $95.0975716 TC $83.5275726 $146.0775726 26 $54.9675726 TC $91.1175731 $169.5775731 26 $57.8575731 TC $111.7275733 $182.5975733 26 $64.3675733 TC $118.2375736 $156.1975736 26 $54.6075736 TC $101.6075741 $147.5275741 26 $63.2775741 TC $84.2475743 $165.5975743 26 $80.2775743 TC $85.3375746 $148.9675746 26 $55.6875746 TC $93.2875756 $170.2975756 26 $56.0475756 TC $114.2575774 $83.5275774 26 $16.9975774 TC $66.5375801 26 $43.7575803 26 $59.6675805 26 $41.22

147 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE75807 26 $56.7675809 $96.5475809 26 $23.8675809 TC $72.6775810 26 $49.5375820 $112.8175820 26 $34.7175820 TC $78.1075822 $131.2575822 26 $51.3475822 TC $79.9075825 $130.8875825 26 $54.9675825 TC $75.9375827 $135.5875827 26 $55.3275827 TC $80.2775831 $137.0375831 26 $54.6075831 TC $82.4475833 $160.8975833 26 $71.5975833 TC $89.3075840 $146.0775840 26 $57.4975840 TC $88.5875842 $177.1675842 26 $75.5775842 TC $101.6075860 $142.4575860 26 $56.0475860 TC $86.4175870 $187.6575870 26 $62.1975870 TC $125.4675872 $146.0775872 26 $57.4975872 TC $88.5875880 $123.6575880 26 $35.4375880 TC $88.2275885 $153.6675885 26 $67.9775885 TC $85.69

148 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE75887 $154.3975887 26 $68.3375887 TC $86.0575889 $140.6575889 26 $54.6075889 TC $86.0575891 $142.4575891 26 $55.3275891 TC $87.1475893 $119.3175893 26 $27.1275893 TC $92.2075894 26 $70.5075898 26 $87.8675901 $202.4775901 26 $23.5075901 TC $178.9775902 $79.5475902 26 $18.8075902 TC $60.7475956 26 $334.0875957 26 $286.3575958 26 $190.5475959 26 $166.3275970 26 $40.1375984 $103.7775984 26 $35.0775984 TC $68.7075989 $122.2175989 26 $58.2175989 TC $64.0076000 $47.3676000 26 $15.1976000 TC $32.1876010 $27.4876010 26 $9.0476010 TC $18.4476080 $57.4976080 26 $26.0376080 TC $31.4676098 $16.6376098 26 $7.9576098 TC $8.6876100 $95.45

149 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE76100 26 $31.0976100 TC $64.3676101 $93.6476101 26 $26.7676101 TC $66.8976102 $146.0776102 26 $33.2676102 TC $112.8176120 $103.4176120 26 $18.4476120 TC $84.9776125 26 $14.1076376 $23.1476376 26 $9.7676376 TC $13.3876377 $71.5976377 26 $39.7776377 TC $31.8276380 $111.3676380 26 $48.8176380 TC $62.5576390 $444.3576390 26 $70.8776390 TC $373.4976391 $239.7176391 26 $56.0476391 TC $183.6776506 $116.7876506 26 $31.8276506 TC $84.9776510 $113.5376510 26 $59.3076510 TC $54.2376511 $69.4276511 26 $36.8876511 TC $32.5476512 $62.1976512 26 $35.4376512 TC $26.7676513 $100.1576513 26 $36.5276513 TC $63.6376514 $12.6576514 26 $8.32

150 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE76514 TC $4.7076516 $54.9676516 26 $23.1476516 TC $31.8276519 $67.2576519 26 $31.8276519 TC $35.4376529 $83.8876529 26 $33.6276529 TC $50.2676536 $116.7876536 26 $28.2076536 TC $88.5876604 $90.0376604 26 $27.1276604 TC $62.9176641 $108.4776641 26 $36.8876641 TC $71.5976642 $88.5876642 26 $34.3576642 TC $54.2376700 $123.2976700 26 $40.8676700 TC $82.4476705 $91.8476705 26 $29.2976705 TC $62.5576706 $114.9876706 26 $27.4876706 TC $87.5076770 $114.2576770 26 $37.2476770 TC $77.0176775 $58.9376775 26 $28.9276775 TC $30.0176776 $157.6476776 26 $38.3376776 TC $119.3176800 $143.5476800 26 $58.2176800 TC $85.3376801 $124.01

151 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE76801 26 $50.2676801 TC $73.7676802 $64.3676802 26 $42.3076802 TC $22.0676805 $142.0976805 26 $50.2676805 TC $91.8476810 $93.6476810 26 $50.2676810 TC $43.3976811 $182.2376811 26 $97.6276811 TC $84.6076812 $203.9276812 26 $91.8476812 TC $112.0876813 $122.9376813 26 $60.7476813 TC $62.1976814 $80.2776814 26 $50.9876814 TC $29.2976815 $85.3376815 26 $32.9076815 TC $52.4376816 $115.3476816 26 $43.3976816 TC $71.9576817 $97.6276817 26 $37.9676817 TC $59.6676818 $122.5776818 26 $54.2376818 TC $68.3376819 $90.0376819 26 $39.4176819 TC $50.6276820 $48.0976820 26 $25.6776820 TC $22.4276821 $93.2876821 26 $36.1676821 TC $57.13

152 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE76825 $279.4876825 26 $84.2476825 TC $195.2476826 $166.3276826 26 $41.5876826 TC $124.7476827 $75.5776827 26 $28.9276827 TC $46.6476828 $53.8776828 26 $28.5676828 TC $25.3176830 $123.6576830 26 $35.0776830 TC $88.5876831 $120.0476831 26 $36.5276831 TC $83.5276856 $111.0076856 26 $34.7176856 TC $76.2976857 $49.1776857 26 $24.9576857 TC $24.2276870 $106.6676870 26 $32.1876870 TC $74.4876872 $130.5276872 26 $33.9976872 TC $96.5476873 $176.4476873 26 $79.1876873 TC $97.2676881 $90.0376881 26 $31.8276881 TC $58.2176882 $57.8576882 26 $24.5976882 TC $33.2676885 $100.1576885 26 $37.6076885 TC $62.5576886 $94.0176886 26 $31.46

153 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE76886 TC $62.5576930 26 $33.6276932 26 $33.6276936 $270.8176936 26 $96.5476936 TC $174.2776937 $34.3576937 26 $14.4676937 TC $19.8976940 26 $101.9676941 26 $69.0676942 $57.4976942 26 $32.1876942 TC $25.3176945 26 $34.7176946 $32.5476946 26 $19.1676946 TC $13.3876948 $75.5776948 26 $34.7176948 TC $40.8676965 $93.6476965 26 $68.3376965 TC $25.3176970 $91.1176970 26 $19.1676970 TC $71.9576975 26 $43.0376977 $7.2376977 26 $2.8976977 TC $4.7076978 $330.1076978 26 $81.3576978 TC $248.7576979 $224.5376979 26 $43.0376979 TC $181.5076981 $109.1976981 26 $30.0176981 TC $79.1876982 $97.6276982 26 $30.0176982 TC $67.6176983 $60.02

154 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE76983 26 $25.6776983 TC $34.3576998 26 $61.8377001 $91.4777001 26 $18.4477001 TC $73.0377002 $102.6877002 26 $27.8477002 TC $74.8477003 $99.4377003 26 $30.3777003 TC $69.0677011 $232.4877011 26 $63.2777011 TC $169.2177012 $152.5877012 26 $74.1277012 TC $78.4677013 26 $193.4377014 $122.5777014 26 $45.1977014 TC $77.3777021 $484.4977021 26 $74.1277021 TC $410.3777022 26 $218.3877046 $252.3777046 26 $73.0377046 TC $179.3377047 $258.8877047 26 $80.6377047 TC $178.2577048 $400.9777048 26 $105.9477048 TC $295.0377049 $409.2877049 26 $115.7077049 TC $293.5977053 $58.2177053 26 $18.0877053 TC $40.1377054 $75.9377054 26 $22.7877054 TC $53.15

155 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE77063 $55.6877063 26 $30.3777063 TC $25.3177065 $135.2277065 26 $40.8677065 TC $94.3777066 $171.3877066 26 $50.6277066 TC $120.7677067 $138.1277067 26 $38.3377067 TC $99.7977071 $50.6277072 $24.2277072 26 $9.4077072 TC $14.8277073 $37.9677073 26 $14.4677073 TC $23.5077074 $68.3377074 26 $22.7877074 TC $45.5677075 $93.2877075 26 $27.1277075 TC $66.1777076 $102.3277076 26 $35.4377076 TC $66.8977077 $39.0577077 26 $16.2777077 TC $22.7877078 $74.8477078 26 $12.2977078 TC $62.5577080 $40.4977080 26 $9.7677080 TC $30.7377081 $33.6277081 26 $10.4977081 TC $23.5077084 $312.3977084 26 $81.3577084 TC $231.0477085 $55.32

156 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE77085 26 $15.1977085 TC $40.1377086 $35.4377086 26 $8.3277086 TC $27.1277261 $71.9577262 $108.4777263 $168.8577280 $282.7477280 26 $37.6077280 TC $245.1477285 $468.2277285 26 $57.4977285 TC $410.7377290 $520.2877290 26 $82.8077290 TC $437.4977293 $470.3977293 26 $106.6677293 TC $363.7377295 $500.0377295 26 $228.1477295 TC $271.8977300 $67.6177300 26 $32.9077300 TC $34.7177301 $1,980.6177301 26 $425.1977301 TC $1,555.4277306 $152.2277306 26 $74.4877306 TC $77.7377307 $294.6777307 26 $154.0277307 TC $140.6577316 $207.5377316 26 $74.8477316 TC $132.6977317 $271.5377317 26 $97.2677317 TC $174.2777318 $390.4877318 26 $154.3977318 TC $236.10

157 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE77321 $95.4577321 26 $50.6277321 TC $44.8377331 $65.8077331 26 $46.2877331 TC $19.5277332 $53.5177332 26 $24.2277332 TC $29.2977333 $111.3677333 26 $39.7777333 TC $71.5977334 $130.5277334 26 $61.1077334 TC $69.4277336 $80.6377338 $507.9977338 26 $228.5077338 TC $279.4877370 $125.1077372 $1,090.8277373 $1,320.4177401 $25.3177417 $11.5777427 $190.1877431 $104.8577432 $426.2877435 $642.8577469 $318.5377470 $133.7877470 26 $107.7477470 TC $26.0377600 $459.5477600 26 $71.9577600 TC $387.5977605 $791.0977605 26 $100.1577605 TC $690.9477610 $706.8577610 26 $69.0677610 TC $637.7977615 $1,085.0477615 26 $97.2677615 TC $987.78

158 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE77620 $524.6277620 26 $83.8877620 TC $440.7477750 $386.1477750 26 $266.1177750 TC $120.0477761 $406.0377761 26 $205.0077761 TC $201.0377762 $537.2877762 26 $307.3277762 TC $229.9577763 $763.9777763 26 $461.7177763 TC $302.2677767 $237.5477767 26 $56.0477767 TC $181.5077768 $364.8177768 26 $74.8477768 TC $289.9777770 $336.2577770 26 $103.4177770 TC $232.8477771 $613.5677771 26 $202.4777771 TC $411.0977772 $929.9377772 26 $287.0877772 TC $642.8577778 $861.9577778 26 $466.0577778 TC $395.9177789 $125.1077789 26 $60.7477789 TC $64.3677790 $15.5578012 $84.2478012 26 $9.7678012 TC $74.4878013 $199.5878013 26 $18.4478013 TC $181.1478014 $250.20

159 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE78014 26 $24.5978014 TC $225.6178015 $232.8478015 26 $33.6278015 TC $199.2278016 $292.8678016 26 $35.0778016 TC $257.7978018 $325.0478018 26 $41.5878018 TC $283.4678020 $86.4178020 26 $28.2078020 TC $58.2178070 $310.2278070 26 $39.4178070 TC $270.8178071 $369.5178071 26 $59.3078071 TC $310.2278072 $403.1478072 26 $77.7378072 TC $325.4078075 $468.5878075 26 $37.6078075 TC $430.9878102 $175.7278102 26 $26.3978102 TC $149.3278103 $225.6178103 26 $35.4378103 TC $190.1878104 $257.4378104 26 $39.0578104 TC $218.3878110 $71.2378110 26 $8.3278110 TC $63.2778111 $75.5778111 26 $9.7678111 TC $66.1778120 $73.0378120 26 $10.1278120 TC $63.27

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE78121 $79.9078121 26 $13.7478121 TC $66.1778122 $97.9878122 26 $21.3378122 TC $76.6578130 $127.9978130 26 $26.0378130 TC $101.9678135 $289.2578135 26 $27.4878135 TC $261.7778140 $112.8178140 26 $25.6778140 TC $87.1478185 $175.3678185 26 $16.9978185 TC $158.3678191 $127.9978191 26 $26.0378191 TC $101.9678195 $369.5178195 26 $59.3078195 TC $310.2278201 $197.7778201 26 $21.3378201 TC $176.4478202 $209.7078202 26 $23.8678202 TC $185.8478205 $218.7478205 26 $33.6278205 TC $185.1278206 $352.1678206 26 $47.0078206 TC $305.1578215 $201.7578215 26 $24.2278215 TC $177.5278216 $131.9778216 26 $27.4878216 TC $104.4978226 $342.7678226 26 $36.88

161 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE78226 TC $305.8878227 $463.5278227 26 $44.8378227 TC $418.6878230 $180.7878230 26 $22.7878230 TC $158.0078231 $107.0278231 26 $22.0678231 TC $84.9778232 $104.8578232 26 $20.2578232 TC $84.9778258 $227.0678258 26 $36.1678258 TC $190.9078261 $210.0778261 26 $29.2978261 TC $180.7878262 $250.2078262 26 $33.2678262 TC $216.9378264 $347.4678264 26 $39.0578264 TC $308.4178265 $402.4178265 26 $48.4578265 TC $353.9778266 $489.1978266 26 $53.5178266 TC $435.6878267 $11.0678268 $94.4178278 $362.2878278 26 $49.5378278 TC $312.7578282 26 $16.6378290 $343.1278290 26 $33.6278290 TC $309.4978291 $266.1178291 26 $43.0378291 TC $223.0878300 $238.63

162 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE78300 26 $31.0978300 TC $207.5378305 $290.6978305 26 $41.2278305 TC $249.4878306 $313.8378306 26 $42.6678306 TC $271.1778315 $359.3978315 26 $50.6278315 TC $308.7778320 $236.8278320 26 $50.9878320 TC $185.8478350 $33.2678350 26 $11.2178350 TC $22.0678351 $15.5578414 26 $22.4278428 $190.1878428 26 $37.9678428 TC $152.2278445 $193.4378445 26 $24.9578445 TC $168.4978451 $351.4378451 26 $67.9778451 TC $283.4678452 $489.5578452 26 $79.9078452 TC $409.6578453 $316.0078453 26 $50.2678453 TC $265.7578454 $451.9578454 26 $66.8978454 TC $385.0678456 $321.4378456 26 $49.1778456 TC $272.2578457 $197.7778457 26 $38.6978457 TC $159.0978458 $212.60

163 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE78458 26 $45.1978458 TC $167.4078459 26 $71.5978466 $203.9278466 26 $35.0778466 TC $168.8578468 $211.5178468 26 $39.7778468 TC $171.7478469 $233.9378469 26 $45.9278469 TC $188.0178472 $236.8278472 26 $48.4578472 TC $188.3778473 $299.3778473 26 $71.9578473 TC $227.4278481 $181.8678481 26 $48.8178481 TC $133.0578483 $245.5078483 26 $71.5978483 TC $173.9178491 26 $71.9578492 26 $91.1178494 $233.9378494 26 $58.5778494 TC $175.3678496 $44.8378496 26 $24.5978496 TC $20.2578579 $193.0778579 26 $24.2278579 TC $168.8578580 $247.3178580 26 $36.8878580 TC $210.4378582 $346.7378582 26 $53.1578582 TC $293.5978597 $208.6278597 26 $36.1678597 TC $172.46

164 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE78598 $316.7278598 26 $41.5878598 TC $275.1578600 $191.2678600 26 $22.0678600 TC $169.2178601 $224.8978601 26 $25.3178601 TC $199.5878605 $206.4578605 26 $26.7678605 TC $179.6978606 $342.4078606 26 $31.8278606 TC $310.5878607 $359.3978607 26 $59.6678607 TC $299.7378608 26 $72.6778609 $75.9378609 26 $75.9378610 $181.5078610 26 $15.1978610 TC $166.3278630 $350.7178630 26 $33.9978630 TC $316.7278635 $351.8078635 26 $31.0978635 TC $320.7078645 $337.7078645 26 $28.2078645 TC $309.4978647 $361.2078647 26 $45.5678647 TC $315.6478650 $284.5578650 26 $26.0378650 TC $258.5178660 $189.4678660 26 $26.7678660 TC $162.7078700 $177.1678700 26 $22.06

165 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE78700 TC $155.1178701 $225.2578701 26 $24.2278701 TC $201.0378707 $240.4478707 26 $46.6478707 TC $193.8078708 $182.2378708 26 $59.6678708 TC $122.5778709 $381.4478709 26 $69.0678709 TC $312.3978710 $184.0378710 26 $27.8478710 TC $156.1978725 $111.7278725 26 $18.4478725 TC $93.2878730 $79.9078730 26 $7.9578730 TC $71.9578740 $226.7078740 26 $27.8478740 TC $198.8678761 $218.7478761 26 $35.7978761 TC $182.9578800 $201.0378800 26 $33.2678800 TC $167.7678801 $266.8378801 26 $39.4178801 TC $227.4278802 $334.4478802 26 $41.9478802 TC $292.5078803 $353.2478803 26 $52.7978803 TC $300.4578804 $590.0678804 26 $52.4378804 TC $537.6478805 $190.54

166 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE78805 26 $36.1678805 TC $154.3978806 $345.2978806 26 $42.3078806 TC $302.9978807 $353.2478807 26 $52.7978807 TC $300.4578808 $40.1378811 26 $75.9378812 26 $93.6478813 26 $96.9078814 26 $107.3878815 26 $120.0478816 26 $121.4879005 $139.5679005 26 $88.9479005 TC $50.6279101 $149.3279101 26 $98.7179101 TC $50.6279200 $137.7579200 26 $84.9779200 TC $52.7979300 26 $68.7079403 $194.5279403 26 $110.6479403 TC $83.8879440 $124.0179440 26 $84.6079440 TC $39.4179445 26 $115.7080047 $13.7380048 $9.4080051 $7.7980053 $11.7480055 $53.1280061 $14.8880069 $9.6580074 $52.9380076 $9.0880081 $83.1880150 $16.7580155 $38.57

167 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE80156 $16.1880157 $14.7380158 $20.0680159 $20.5580162 $14.7580163 $14.7580164 $15.0580165 $15.0580168 $18.1580169 $15.2680170 $18.2080171 $21.6780173 $16.1880175 $14.7380176 $16.3280177 $14.7380178 $7.3580180 $20.0680183 $14.7380184 $15.3080185 $14.7380186 $15.2980188 $18.4480190 $60.0080192 $18.6180194 $16.2280195 $15.2680197 $15.2680198 $15.7180199 $27.1180200 $17.9280201 $13.2480202 $15.0580203 $14.7380299 $18.6480305 $12.6080306 $17.1480307 $64.6580400 $36.2480402 $96.6280406 $86.9580408 $139.4480410 $29.7780412 $801.62

168 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE80414 $57.3780415 $62.0980416 $209.3280417 $48.8880418 $643.8480420 $161.8880422 $51.1980424 $56.1180426 $164.9080428 $74.1280430 $129.3380432 $165.6180434 $285.0380435 $114.4580436 $101.2980438 $56.0180439 $74.6880500 $23.1480502 $74.8481000 $4.0281001 $3.5281002 $3.4881003 $2.4981005 $2.4181007 $29.9881015 $3.3981020 $4.7081025 $8.6181050 $3.6481105 $135.8081106 $135.8081107 $135.8081108 $135.8081109 $135.8081110 $135.8081111 $135.8081112 $135.8081120 $193.2581121 $295.7981161 $279.0081162 $2,027.6481163 $468.0081164 $584.2381165 $282.88

169 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE81166 $301.3581167 $282.8881170 $300.0081171 $137.0081172 $274.8381173 $301.3581174 $185.2081175 $676.5081176 $268.7781177 $137.0081178 $137.0081179 $137.0081180 $137.0081181 $137.0081182 $137.0081183 $137.0081184 $137.0081185 $846.2781186 $185.2081187 $137.0081188 $137.0081189 $274.8381190 $185.2081200 $47.2581201 $780.0081202 $280.0081203 $200.0081204 $137.0081205 $94.9981206 $182.1881207 $160.9381208 $214.6281209 $39.3181210 $175.4081212 $440.0081215 $375.2581216 $185.1281217 $375.2581218 $268.7781219 $135.1481220 $556.6081221 $97.2281222 $435.0781223 $499.00

170 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE81224 $168.7581225 $291.3681226 $450.9181227 $174.8181228 $900.0081229 $1,160.0081230 $174.8181231 $174.8181232 $174.8181233 $175.4081234 $137.0081235 $324.5881236 $282.8881237 $175.4081238 $600.0081239 $274.8381240 $65.6981241 $73.3781242 $36.6281243 $57.0481244 $44.8981245 $165.5181246 $83.0081247 $174.8181248 $375.2581249 $600.0081250 $58.4981251 $47.2581252 $101.1281253 $61.5281254 $35.0081255 $51.4581256 $72.6281257 $102.2681258 $375.2581259 $600.0081260 $39.3181261 $219.9981262 $68.5581263 $327.2481264 $172.7381265 $238.9481266 $304.8181267 $230.51

171 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE81268 $289.7681269 $202.4081270 $101.8581271 $137.0081272 $329.5181273 $124.8781274 $274.8381275 $193.2581276 $193.2581283 $73.3781284 $137.0081285 $274.8381286 $274.8381287 $124.6481288 $192.3281289 $185.2081290 $39.3181291 $65.3481292 $675.4081293 $331.0081294 $202.4081295 $381.7081296 $337.7381297 $213.3081298 $641.8581299 $308.0081300 $238.0081301 $348.5681302 $527.8781303 $120.0081304 $150.0081305 $175.4081306 $291.3681310 $246.5281311 $295.7981312 $137.0081313 $255.0581314 $329.5181315 $230.3581316 $230.3581317 $676.5081318 $331.0081319 $203.5081320 $291.36

172 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE81321 $600.0081322 $47.5681323 $300.0081324 $758.3681325 $769.5881326 $47.5681327 $192.0081328 $174.8181329 $137.0081330 $47.0081331 $51.0781332 $48.5081333 $137.0081334 $329.5181335 $174.8181336 $301.3581337 $185.2081340 $232.1381341 $55.1081342 $223.8881343 $137.0081344 $137.0081345 $185.2081346 $174.8181350 $234.0081355 $88.2081361 $174.8181362 $375.2581363 $202.4081364 $324.5881370 $446.8081371 $404.5281372 $403.5981373 $127.4381374 $80.8381375 $245.2781376 $135.8081377 $102.0181378 $383.9681379 $372.6581380 $196.9481381 $169.9081382 $137.4281383 $121.26

173 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE81400 $63.9681401 $137.0081402 $150.3381403 $185.2081404 $274.8381405 $301.3581406 $282.8881407 $846.2781408 $2,000.0081410 $504.0081411 $1,350.1981412 $2,448.5681413 $649.8981414 $649.8981415 $4,780.0081416 $12,000.0081417 $320.0081420 $759.0581422 $759.0581425 $5,031.2081426 $2,709.9581427 $2,337.6581430 $1,625.0081431 $679.5781432 $754.5081433 $487.7081434 $597.9181435 $649.8981436 $649.8981437 $487.7081438 $487.7081439 $649.8981440 $3,324.0081442 $2,143.6081443 $2,448.5681445 $597.9181448 $649.8981450 $759.5381455 $2,919.6081460 $1,287.0081465 $936.0081470 $914.0081471 $914.0081490 $840.65

174 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE81493 $1,050.0081500 $260.5081503 $897.0081504 $520.0081506 $74.6781507 $795.0081508 $54.3081509 $1,487.3781510 $55.5481511 $153.5081512 $69.5281518 $3,873.0081519 $3,873.0081520 $2,789.1281521 $3,873.0081525 $3,116.0081528 $508.8781535 $579.4681536 $177.5681538 $2,871.0081539 $760.0081540 $3,750.0081541 $3,873.0081545 $3,600.0081551 $2,030.0081595 $3,240.0081596 $72.1982009 $5.0282010 $9.0882013 $12.4182016 $16.4982017 $18.7482024 $42.9182030 $28.6782040 $5.5082042 $7.7882043 $6.4282044 $6.2382045 $37.7182075 $30.0082085 $10.7982088 $45.2882103 $14.9382104 $16.07

175 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE82105 $18.6482106 $18.6482107 $71.5782108 $28.3182120 $5.9982127 $15.4182128 $15.4182131 $22.9882135 $18.2882136 $19.6182139 $18.7482140 $16.1982143 $9.3582150 $7.2082154 $32.0482157 $32.5382160 $27.7882163 $22.8082164 $16.2282172 $21.0982175 $21.0882180 $10.9882190 $16.5682232 $17.9782239 $19.0382240 $29.5382247 $5.5782248 $5.5782252 $5.0682261 $18.7482270 $4.3882271 $5.3282272 $4.2382274 $17.6782286 $5.7382300 $25.7282306 $32.8982308 $29.7782310 $5.7382330 $15.2082331 $13.3482340 $6.7082355 $12.8682360 $14.30

176 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE82365 $14.3382370 $13.9282373 $20.0682374 $5.4382375 $13.6982376 $14.0782378 $21.0782379 $18.7482380 $10.2582382 $27.3082383 $29.0882384 $28.0682387 $20.0682390 $11.9382397 $15.6982415 $14.0882435 $5.1182436 $5.7582438 $5.4382441 $6.6782465 $4.8482480 $8.7582482 $9.8182485 $22.9582495 $22.5382507 $30.8982523 $20.7682525 $13.7982528 $25.0282530 $18.5782533 $18.1182540 $5.1582542 $24.0982550 $7.2382552 $14.8882553 $12.8382554 $13.1982565 $5.6982570 $5.7582575 $10.5182585 $14.1482595 $7.1882600 $21.5582607 $16.75

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE82608 $15.9182610 $18.5282615 $9.5582626 $28.0882627 $24.7182633 $34.4382634 $32.5382638 $13.6182642 $32.5382652 $42.7882656 $12.8182657 $22.1782658 $44.0382664 $61.5082668 $20.8882670 $31.0482671 $35.8982672 $24.1182677 $26.8782679 $27.7382693 $16.5682696 $26.2482705 $5.6682710 $18.6782715 $22.9782725 $18.7782726 $20.0682728 $15.1582731 $71.5782735 $20.6082746 $16.3482747 $19.2582757 $19.2682759 $23.8782760 $12.4482775 $23.4182776 $11.7482777 $44.2582784 $10.3482785 $18.2982787 $8.9182800 $11.0082803 $26.0782805 $78.77

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE82810 $9.7782820 $13.3482930 $6.7182938 $19.6682941 $19.5982943 $15.8882945 $4.3782946 $17.7782947 $4.3782948 $5.0482950 $5.2782951 $14.3082952 $4.3682955 $10.7782960 $6.7282962 $3.2882963 $23.8782965 $13.1582977 $8.0082978 $15.8482979 $10.4982985 $16.7683001 $20.6583002 $20.5783003 $18.5283006 $75.6083009 $74.8483010 $13.9783012 $26.8983013 $74.8483014 $8.7383015 $20.9483018 $24.4183020 $14.3083020 26 $18.8083021 $20.0683026 $4.0183030 $10.7483033 $8.0083036 $10.7983037 $10.7983045 $6.4983050 $8.2083051 $8.12

179 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE83060 $9.1983065 $9.0083068 $9.4783069 $4.3983070 $5.2783080 $18.7483088 $32.8183090 $18.7483150 $22.4183491 $19.4783497 $14.3383498 $30.1983500 $25.1783505 $27.0183516 $12.8183518 $9.6483519 $18.4083520 $17.2783525 $12.7083527 $14.3983528 $19.8283540 $7.1983550 $9.7183570 $9.8383582 $15.7583586 $14.2283593 $29.2283605 $11.8783615 $6.7183625 $14.2283630 $21.8183631 $21.8183632 $22.4783633 $11.2583655 $13.4583661 $24.4383662 $21.0183663 $21.0183664 $21.0183670 $10.1883690 $7.6583695 $14.3983698 $46.3183700 $12.51

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE83701 $33.8683704 $35.0683718 $9.1083719 $12.9383721 $10.6083722 $35.0683727 $19.1083735 $7.4483775 $8.1983785 $27.3383789 $24.1183825 $18.0683835 $18.8283857 $11.9383861 $22.4883864 $28.5083872 $6.5183873 $19.1283874 $14.3583876 $50.8683880 $39.2683883 $15.1183885 $27.2383915 $12.3983916 $27.3983918 $23.6083919 $18.2883921 $21.2183930 $7.3583935 $7.5783937 $33.1683945 $14.4583950 $71.5783951 $71.5783970 $45.8683986 $3.9883987 $3.9883992 $18.1583993 $21.8184030 $6.1184035 $4.0784060 $8.2184066 $10.7384075 $5.75

181 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE84078 $8.2684080 $16.4384081 $18.3584085 $10.4984087 $11.4784100 $5.2784105 $5.7884106 $5.8284110 $9.3884112 $98.1184119 $13.3684120 $16.3584126 $39.1184132 $5.1184133 $4.7984134 $16.2184135 $21.2784138 $21.0584140 $22.9784143 $25.3484144 $23.1884145 $29.7784146 $21.5384150 $41.7784152 $20.4484153 $20.4484154 $20.4484155 $4.0784156 $4.0784157 $4.0784160 $5.7584163 $16.7384165 $11.9384165 26 $18.8084166 $19.8184166 26 $18.8084181 $18.9284181 26 $18.8084182 $29.2184182 26 $18.8084202 $15.9484203 $9.7484206 $26.6984207 $31.22

182 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE84210 $14.4884220 $10.4984228 $12.9384233 $87.8884234 $72.0984235 $71.2384238 $40.6384244 $24.4484252 $22.4984255 $28.3784260 $34.4384270 $24.1584275 $14.9384285 $26.1584295 $5.3584300 $5.4084302 $5.4084305 $23.6384307 $20.3184311 $8.1084315 $3.2884375 $39.0084376 $6.1184377 $6.1184378 $12.8184379 $12.8184392 $5.4984402 $28.3084403 $28.6884410 $56.9884425 $23.5984430 $12.9384431 $35.1184432 $17.8484436 $7.6384437 $7.1884439 $10.0284442 $16.4384443 $18.6784445 $56.5184446 $15.7584449 $20.0084450 $5.7584460 $5.89

183 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE84466 $14.1884478 $6.3884479 $7.1884480 $15.7584481 $18.8284482 $17.5184484 $12.4784485 $8.0084488 $8.1184490 $9.9384510 $11.5684512 $10.0984520 $4.3984525 $5.1384540 $5.5684545 $7.3584550 $5.0284560 $5.2784577 $18.6784578 $4.4784580 $9.5584583 $6.0584585 $17.2284586 $39.2684588 $37.7184590 $12.9084591 $17.0684597 $15.2484600 $17.8784620 $13.1684630 $12.6584681 $23.1384702 $16.7384703 $8.3684704 $16.7384830 $12.7085002 $5.0185004 $7.1885007 $3.8285008 $3.8285009 $5.0785013 $7.0085014 $2.6385018 $2.63

184 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE85025 $8.6385027 $7.1885032 $4.7985041 $3.3585044 $4.7985045 $4.4485046 $6.1985048 $2.8285049 $4.9785055 $35.7485060 $24.9585097 $75.5785130 $13.2185170 $16.3085175 $20.3785210 $14.4385220 $19.6185230 $19.8985240 $19.8985244 $22.6985245 $25.4985246 $25.4985247 $25.4985250 $21.1685260 $19.8985270 $19.8985280 $21.5085290 $18.1585291 $9.8885292 $21.0485293 $21.0485300 $13.1785301 $12.0185302 $13.3585303 $15.3785305 $12.9085306 $17.0385307 $17.0385335 $14.3085337 $17.2785345 $4.7985347 $4.7385348 $4.4985360 $9.34

185 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE85362 $7.6585366 $80.4685370 $12.6285378 $9.7285379 $11.3185380 $11.3185384 $9.7285385 $14.4685390 $15.4885390 26 $37.9685396 $20.6185397 $30.8685400 $8.5685410 $8.5685415 $19.1085420 $7.2685421 $11.3285441 $4.6785445 $7.5785460 $8.5985461 $9.3685475 $9.8685520 $14.5585525 $13.1585530 $14.5585536 $7.1885540 $9.5685547 $9.5685549 $20.8385555 $7.4785557 $14.8485576 $24.9185576 26 $18.8085597 $19.9785598 $19.9785610 $4.3785611 $4.3885612 $17.4985613 $10.6485635 $10.9485651 $4.2785652 $3.0085660 $6.1285670 $6.41

186 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE85675 $7.6185705 $10.7085730 $6.6785732 $7.1885810 $12.9786000 $7.7686001 $7.8286003 $5.8086005 $8.8586008 $19.9386021 $16.7386022 $20.4186023 $13.8486038 $13.4386039 $12.4086060 $8.1186063 $6.4186077 $56.0486078 $56.0486079 $55.6886140 $5.7586141 $14.3986146 $28.2886147 $28.2886148 $17.8586152 $273.0086153 26 $35.0786155 $17.7686156 $8.0786157 $8.9686160 $13.3386161 $13.3386162 $22.5886171 $11.1286200 $14.3986215 $14.7286225 $15.2786226 $13.4586235 $19.9386255 $13.3986255 26 $18.8086256 $13.3986256 26 $18.8086277 $17.49

187 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE86280 $9.1086294 $25.5786300 $23.1386301 $23.1386304 $23.1386305 $23.1386308 $5.7586309 $7.1886310 $8.1986316 $23.1386317 $16.6586318 $18.0986320 $29.9286320 26 $18.8086325 $24.8586325 26 $18.8086327 $29.9286327 26 $23.1486329 $15.6186331 $13.3186332 $27.0886334 $24.8386334 26 $18.8086335 $32.6186335 26 $18.8086336 $17.3286337 $23.7986340 $16.7586341 $23.5786343 $13.8486344 $10.3986352 $150.9686353 $54.4786355 $41.9286356 $29.7586357 $41.9286359 $41.9286360 $52.2086361 $29.7586367 $77.7886376 $16.1786382 $18.7986384 $13.6186386 $21.78

188 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE86403 $11.5486406 $11.8286430 $6.3086431 $6.3086480 $68.8786481 $100.0086486 $5.4286490 $90.0386510 $6.8786580 $8.6886590 $12.6686592 $4.7586593 $4.8986602 $11.3186603 $14.3086606 $16.7386609 $14.3186611 $11.3186612 $14.3486615 $14.6586617 $17.2186618 $18.9286619 $14.8686622 $9.9286625 $14.5886628 $13.3486631 $13.1486632 $14.0986635 $12.7586638 $13.4786641 $16.0186644 $15.9986645 $18.7286648 $16.9086651 $14.6586652 $14.6586653 $14.6586654 $14.6586658 $14.4786663 $14.5886664 $16.9986665 $20.1686666 $11.3186668 $14.16

189 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE86671 $13.6286674 $16.3586677 $16.8586682 $14.4586684 $17.6086687 $9.3286688 $15.5686689 $21.5186692 $19.0786694 $15.9986695 $14.6586696 $21.5186698 $13.8886701 $9.8786702 $15.0286703 $15.2386704 $13.3986705 $13.0886706 $11.9386707 $12.8586708 $13.7686709 $12.5186710 $15.0686711 $16.8986713 $17.0086717 $13.6186720 $16.2086723 $14.6586727 $14.3086732 $15.0086735 $14.5086738 $14.7186741 $14.6586744 $15.9986747 $16.7086750 $14.6586753 $13.7686756 $15.8986757 $21.5186759 $18.2386762 $15.9986765 $14.3186768 $14.6586771 $24.48

190 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE86774 $16.4486777 $15.9986778 $16.0186780 $14.7186784 $13.9686787 $14.3186788 $18.7286789 $15.9986790 $14.3186793 $14.6586794 $18.7286800 $17.6786803 $15.8586804 $17.2186805 $189.5186806 $52.8886807 $78.6586808 $32.9886812 $28.6786813 $64.4486816 $30.9586817 $106.1486821 $40.6286825 $109.4986826 $36.5386828 $64.1986829 $64.1986830 $95.5286831 $81.8886832 $323.7586833 $325.8086834 $397.2986835 $358.8586850 $9.7786880 $5.9986885 $6.3686886 $5.7586900 $3.3286901 $3.3286902 $6.3586904 $16.3486905 $4.2586906 $8.6186940 $9.11

191 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE86941 $13.4587003 $18.7187015 $7.4287040 $11.4787045 $10.4987046 $10.4987070 $9.5787071 $10.4987073 $10.4987075 $10.5287076 $8.9787077 $8.9787081 $7.3687084 $27.0787086 $8.9787088 $8.9987101 $8.5687102 $9.3487103 $20.4687106 $11.4787107 $11.4787109 $17.1087110 $21.7787116 $12.0087118 $14.6187140 $6.1987143 $13.9287147 $5.7587149 $22.2887150 $38.9987152 $7.7487153 $128.1787158 $7.7487164 $11.9387164 26 $20.6187166 $12.5687168 $4.7587169 $4.7587172 $4.7587176 $6.5487177 $9.8987181 $5.2787184 $7.6687185 $5.27

192 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE87186 $9.6187187 $40.1787188 $7.3887190 $7.3187197 $16.6987205 $4.7587206 $5.9987207 $6.6687207 26 $18.8087209 $19.9787210 $5.8287220 $4.7587230 $21.9387250 $21.7387252 $28.9787253 $22.4587254 $21.7387255 $37.6287260 $14.4387265 $13.3287267 $13.4287269 $13.6187270 $13.3287271 $13.4287272 $13.3287273 $13.3287274 $13.3287275 $13.3287276 $16.0787278 $15.6087279 $16.4387280 $13.4287281 $13.3287283 $60.8087285 $13.3287290 $13.4287299 $16.1087300 $13.3287301 $13.3287305 $13.3287320 $15.0087324 $13.3287327 $13.4287328 $13.82

193 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE87329 $13.3287332 $13.3287335 $13.3287336 $16.0087337 $13.3287338 $15.9887339 $16.0087340 $11.4887341 $11.4887350 $12.8187380 $18.3687385 $13.3287389 $26.7587390 $24.0687391 $21.9087400 $14.1387420 $13.9187425 $13.3287427 $13.3287430 $16.8187449 $13.3287450 $10.6687451 $10.6687471 $38.9987472 $47.6087475 $22.2887476 $38.9987480 $22.2887481 $38.9987482 $55.7487483 $463.0987485 $22.2887486 $38.9987487 $47.6087490 $22.7587491 $38.9987492 $53.4787493 $38.9987495 $30.0387496 $38.9987497 $47.6087498 $38.9987500 $38.9987501 $57.02

194 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE87502 $95.8087503 $29.2287505 $142.5487506 $262.9987507 $463.0987510 $22.2887511 $38.9987512 $46.4087516 $38.9987517 $47.6087520 $31.2287521 $38.9987522 $47.6087525 $29.8087526 $39.2687527 $46.4087528 $22.2887529 $38.9987530 $47.6087531 $58.0087532 $38.9987533 $46.4087534 $22.2887535 $38.9987536 $94.5587537 $22.2887538 $38.9987539 $58.6287540 $22.2887541 $38.9987542 $46.4087550 $22.2887551 $48.2487552 $47.6087555 $26.8887556 $41.6887557 $47.6087560 $27.2987561 $38.9987562 $47.6087580 $22.2887581 $38.9987582 $302.6287590 $26.88

195 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE87591 $38.9987592 $47.6087623 $38.9987624 $38.9987625 $40.5587631 $142.6387632 $237.1487633 $463.0987634 $77.9987640 $38.9987641 $38.9987650 $22.2887651 $38.9987652 $46.4087653 $38.9987660 $22.2887661 $38.9987662 $57.0287797 $30.0387798 $38.9987799 $47.6087800 $44.5787801 $77.9987802 $13.3287803 $16.0087804 $16.5587806 $32.7787807 $13.3287808 $15.2987809 $21.7687810 $35.2987850 $24.5687880 $16.5387899 $16.0787900 $144.8387901 $286.0587902 $286.0587903 $542.9587904 $28.9787905 $13.5887906 $143.0387910 $286.0587912 $286.0588104 $71.23

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE88104 26 $29.2988104 TC $41.9488106 $65.0888106 26 $19.8988106 TC $45.1988108 $61.4688108 26 $23.1488108 TC $38.3388112 $68.3388112 26 $28.9288112 TC $39.4188120 $609.9588120 26 $60.0288120 TC $549.9388121 $489.5588121 26 $50.9888121 TC $438.5788125 $26.7688125 26 $14.1088125 TC $12.6588130 $19.9788140 $8.8888141 $32.1888142 $22.5188143 $23.0488147 $50.5688148 $16.8888150 $14.9988152 $27.6488153 $24.0388155 $14.6588160 $72.3188160 26 $26.7688160 TC $45.5688161 $67.2588161 26 $26.0388161 TC $41.2288162 $96.9088162 26 $39.7788162 TC $57.1388164 $14.9988165 $42.2288166 $14.9988167 $14.99

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE88172 $57.4988172 26 $37.6088172 TC $19.8988173 $155.4788173 26 $73.7688173 TC $81.7188174 $25.3788175 $29.4488177 $30.3788177 26 $23.1488177 TC $7.2388182 $136.3188182 26 $40.1388182 TC $96.1788184 $67.6188185 $24.9588187 $38.6988188 $65.0888189 $87.1488230 $129.4488233 $156.3688235 $163.6388237 $143.7588239 $163.9188240 $13.0788241 $12.0988245 $192.4288248 $192.4288249 $192.4288261 $264.3488262 $138.4988263 $166.9988264 $144.6188267 $199.7588269 $184.8188271 $23.8088272 $40.7088273 $35.7088274 $42.3888275 $51.1988280 $33.4788283 $76.2288285 $26.9188289 $38.26

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE88291 $33.6288300 $15.9188300 26 $4.3488300 TC $11.5788302 $31.0988302 26 $6.8788302 TC $24.2288304 $40.8688304 26 $11.5788304 TC $29.2988305 $70.1488305 26 $39.4188305 TC $30.7388307 $273.3488307 26 $86.4188307 TC $186.9388309 $415.0788309 26 $152.5888309 TC $262.4988311 $21.6988311 26 $12.6588311 TC $9.0488312 $101.9688312 26 $27.4888312 TC $74.4888313 $73.7688313 26 $12.2988313 TC $61.4688314 $93.6488314 26 $23.1488314 TC $70.5088319 $98.7188319 26 $27.4888319 TC $71.2388321 $101.6088323 $117.8788323 26 $90.7588323 TC $27.1288325 $182.9588329 $52.4388331 $98.7188331 26 $65.0888331 TC $33.6288332 $54.23

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE88332 26 $32.1888332 TC $22.0688333 $90.7588333 26 $65.0888333 TC $25.6788334 $56.7688334 26 $39.7788334 TC $16.9988341 $94.7388341 26 $30.0188341 TC $64.7288342 $108.4788342 26 $36.8888342 TC $71.5988344 $174.6388344 26 $40.1388344 TC $134.5088346 $112.0888346 26 $37.6088346 TC $74.4888348 $365.5488348 26 $79.1888348 TC $286.3588350 $78.8288350 26 $30.0188350 TC $48.8188355 $135.2288355 26 $85.3388355 TC $49.9088356 $227.7888356 26 $130.1688356 TC $97.6288358 $130.1688358 26 $52.0688358 TC $78.1088360 $129.8088360 26 $44.1188360 TC $85.6988361 $134.1488361 26 $47.3688361 TC $86.7788362 $212.6088362 26 $115.3488362 TC $97.26

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE88363 $23.8688364 $134.8688364 26 $36.1688364 TC $98.7188365 $180.0688365 26 $45.5688365 TC $134.5088366 $268.2888366 26 $64.3688366 TC $203.9288367 $111.0088367 26 $35.7988367 TC $75.2088368 $129.4488368 26 $43.3988368 TC $86.0588369 $113.1788369 26 $33.6288369 TC $79.5488371 $24.7088371 26 $20.6188372 $26.2288372 26 $18.8088373 $76.2988373 26 $28.2088373 TC $48.0988374 $331.5588374 26 $45.9288374 TC $285.6388375 $50.6288377 $394.4688377 26 $66.8988377 TC $327.5788380 $135.9588380 26 $57.1388380 TC $78.8288381 $156.5588381 26 $26.3988381 TC $130.1688387 $35.7988387 26 $28.9288387 TC $6.8788388 $35.7988388 26 $24.59

201 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE88388 TC $11.2188720 $5.5788738 $5.5788740 $9.3788741 $9.3789049 $253.0989050 $5.2589051 $6.1289055 $4.7589060 $7.9589060 26 $18.8089125 $5.8889160 $4.8589190 $5.7989220 $16.6389230 $2.8989300 $11.0389320 $13.3989321 $14.8889322 $17.2289330 $10.9989331 $21.7690371 $119.5490375 $307.0290376 $311.9990471 $15.8090472 $15.8090473 $15.8090474 $15.8090785 $15.1990791 $138.8490792 $155.4790832 $67.9790833 $70.1490834 $90.3990836 $88.5890837 $135.5890838 $117.1490839 $141.3790840 $67.9790845 $96.1790846 $109.1990847 $113.5390849 $41.94

202 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE90853 $27.1290865 $171.3890870 $177.5290875 $64.0090876 $108.4790880 $106.3090887 $88.2290901 $40.4990911 $88.2290935 $73.4090937 $104.4990945 $86.0590947 $124.3890951 $943.3090954 $814.2390955 $459.1890956 $319.6290957 $645.0290958 $438.2190959 $298.2990960 $284.9190961 $239.7190962 $185.4890963 $547.4090964 $477.9890965 $455.5690966 $238.9990967 $18.0890968 $15.9190969 $15.1990970 $7.9590989 $623.4390997 $89.6791010 $193.0791010 26 $67.6191010 TC $125.4691013 $26.3991013 26 $9.7691013 TC $16.6391020 $252.0191020 26 $75.9391020 TC $176.0891022 $171.7491022 26 $75.93

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE91022 TC $95.8191030 $140.6591030 26 $48.0991030 TC $92.5691034 $193.4391034 26 $50.9891034 TC $142.4591035 $492.4491035 26 $83.8891035 TC $408.5691037 $167.4091037 26 $51.3491037 TC $116.0691038 $453.0391038 26 $57.8591038 TC $395.1891040 $488.1091040 26 $50.6291040 TC $437.4991065 $76.6591065 26 $10.4991065 TC $66.5391110 $894.8691110 26 $130.8891110 TC $763.9791111 $816.7691111 26 $52.7991111 TC $763.9791112 $1,292.9391112 26 $110.2891112 TC $1,182.6691117 $140.2891120 $466.7791120 26 $50.2691120 TC $416.5191122 $245.5091122 26 $91.4791122 TC $154.0291132 $245.5091132 26 $27.4891132 TC $218.0291133 $268.2891133 26 $34.7191133 TC $233.57

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE91200 $39.4191200 26 $14.1091200 TC $25.3192002 $85.3392004 $152.9492012 $89.3092014 $127.9992015 $19.8992018 $147.5292019 $73.4092020 $28.2092025 $38.3392025 26 $20.2592025 TC $18.0892060 $65.4492060 26 $38.6992060 TC $26.7692065 $54.2392065 26 $18.0892065 TC $36.1692081 $34.3592081 26 $16.2792081 TC $18.0892082 $48.4592082 26 $21.6992082 TC $26.7692083 $65.0892083 26 $28.2092083 TC $36.8892100 $83.5292132 $31.8292132 26 $16.6392132 TC $15.1992133 $37.6092133 26 $22.4292133 TC $15.1992134 $41.5892134 26 $26.0392134 TC $15.5592136 $71.2392136 26 $31.8292136 TC $39.4192145 $17.3592145 26 $9.40

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE92145 TC $7.9592225 $28.2092226 $26.0392227 $14.4692228 $34.7192228 26 $20.9792228 TC $13.7492230 $65.8092235 $93.2892235 26 $44.1192235 TC $49.1792240 $209.7092240 26 $47.7392240 TC $161.9892242 $235.0192242 26 $56.0492242 TC $178.9792250 $51.3492250 26 $22.0692250 TC $29.2992260 $19.8992265 $89.3092265 26 $47.7392265 TC $41.5892270 $96.9092270 26 $42.6692270 TC $54.2392273 $136.3192273 26 $37.9692273 TC $98.3492274 $92.2092274 26 $33.6292274 TC $58.5792283 $54.6092283 26 $9.4092283 TC $45.5692284 $62.5592284 26 $12.6592284 TC $49.9092285 $21.6992285 26 $3.2592285 TC $18.8092286 $39.4192286 26 $22.42

206 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE92286 TC $16.9992287 $148.9692287 26 $48.0992287 TC $100.8792340 $35.4392341 $40.8692342 $44.1192352 $41.9492353 $48.8192354 $13.7492355 $21.3392358 $11.5792370 $31.4692371 $11.9392502 $96.9092504 $30.0192507 $79.9092508 $24.2292511 $113.1792512 $60.0292516 $69.7892520 $79.9092521 $114.9892522 $92.5692523 $198.5092524 $89.6792526 $87.5092537 $41.5892537 26 $32.1892537 TC $9.4092538 $21.3392538 26 $15.9192538 TC $5.4292540 $105.5792540 26 $80.2792540 TC $25.3192541 $25.3192541 26 $21.3392541 TC $3.9892542 $29.2992542 26 $25.6792542 TC $3.6292544 $17.3592544 26 $14.46

207 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE92544 TC $2.8992545 $16.2792545 26 $13.3892545 TC $2.8992546 $106.3092546 26 $15.5592546 TC $90.7592547 $7.5992548 $97.9892548 26 $26.3992548 TC $71.5992550 $22.0692551 $11.9392552 $32.1892553 $39.0592555 $24.5992556 $38.6992557 $38.6992558 $10.1292561 $39.4192562 $46.2892563 $31.4692564 $25.6792565 $15.5592567 $15.5592568 $15.9192570 $32.9092571 $27.4892572 $43.3992575 $64.3692576 $37.2492577 $14.1092579 $47.0092582 $74.1292583 $48.8192584 $75.2092585 $137.0392585 26 $27.1292585 TC $109.9192586 $94.0192587 $22.0692587 26 $18.4492587 TC $3.6292588 $33.62

208 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE92588 26 $29.2992588 TC $4.3492590 $115.3192591 $115.3192592 $25.3292593 $25.3292594 $25.3292595 $25.3292596 $68.3392601 $167.7692602 $104.8592603 $156.5592604 $93.2892606 $83.5292609 $110.6492610 $87.5092611 $90.7592612 $194.8892613 $37.9692614 $144.2692615 $33.2692616 $209.7092617 $41.9492620 $95.4592621 $23.1492625 $71.2392626 $91.4792627 $23.1492640 $116.4292920 $522.8192924 $622.9692928 $581.3992933 $651.8992937 $581.0292941 $653.7092943 $653.3492950 $316.3692953 $1.0892960 $160.8992961 $245.1492970 $185.8492971 $98.7192973 $173.9192974 $159.09

209 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE92975 $370.6092977 $54.6092978 26 $94.7392979 26 $75.5792986 $1,300.8992987 $1,343.5592990 $1,071.6692997 $642.8592998 $318.1793000 $16.9993005 $8.6893010 $8.6893015 $71.9593016 $22.4293017 $34.7193018 $15.1993024 $111.7293024 26 $57.8593024 TC $53.8793025 $152.2293025 26 $37.2493025 TC $114.9893040 $12.6593041 $5.7893042 $7.2393050 $16.2793050 26 $8.3293050 TC $7.9593224 $90.0393225 $26.3993226 $37.2493227 $26.7693228 $26.3993229 $720.2293260 $69.0693260 26 $43.3993260 TC $25.6793261 $63.2793261 26 $37.6093261 TC $25.6793264 $51.3493268 $205.3693270 $9.4093271 $170.66

210 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE93272 $25.6793278 $31.0993278 26 $12.6593278 TC $18.4493279 $56.0493279 26 $32.9093279 TC $23.1493280 $65.4493280 26 $38.6993280 TC $26.7693281 $70.5093281 26 $43.3993281 TC $27.1293282 $67.9793282 26 $43.0393282 TC $24.9593283 $85.6993283 26 $58.5793283 TC $27.1293284 $92.5693284 26 $63.6393284 TC $28.9293285 $49.1793285 26 $26.7693285 TC $22.4293286 $35.4393286 26 $15.1993286 TC $20.2593287 $43.7593287 26 $23.5093287 TC $20.2593288 $44.8393288 26 $21.6993288 TC $23.1493289 $60.7493289 26 $37.6093289 TC $23.1493290 $42.6693290 26 $22.0693290 TC $20.6193291 $38.3393291 26 $18.4493291 TC $19.8993292 $40.86

211 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE93292 26 $21.6993292 TC $19.1693293 $53.1593293 26 $15.1993293 TC $37.9693294 $30.7393295 $44.8393296 $26.0393297 $26.7693298 $26.7693303 $239.3593303 26 $64.7293303 TC $174.6393304 $163.0693304 26 $36.8893304 TC $126.1893306 $210.0793306 26 $74.4893306 TC $135.5893307 $142.8293307 26 $45.5693307 TC $97.2693308 $100.1593308 26 $26.0393308 TC $74.1293312 $250.2093312 26 $111.0093312 TC $139.2093313 $11.5793314 $240.0793314 26 $91.4793314 TC $148.6093315 26 $130.5293316 $27.8493317 26 $92.9293318 26 $105.2193320 $54.6093320 26 $18.8093320 TC $35.7993321 $27.4893321 26 $7.5993321 TC $19.8993325 $25.6793325 26 $3.25

212 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE93325 TC $22.4293350 $190.9093350 26 $71.9593350 TC $118.9593351 $236.1093351 26 $86.4193351 TC $149.6993352 $33.9993355 $232.4893451 $792.1793451 26 $129.0893451 TC $663.1093452 $874.9793452 26 $235.7493452 TC $639.2393453 $1,133.4893453 26 $315.6493453 TC $817.8493454 $882.9293454 26 $238.2793454 TC $644.6693455 $1,017.4293455 26 $277.6893455 TC $739.7593456 $1,117.9493456 26 $309.8693456 TC $808.0893457 $1,249.1893457 26 $348.1893457 TC $901.0093458 $1,047.4393458 26 $294.3193458 TC $753.1393459 $1,149.7593459 26 $332.9993459 TC $816.7693460 $1,255.6993460 26 $372.4093460 TC $883.2993461 $1,422.0193461 26 $412.1893461 TC $1,009.8393462 $206.8193463 $99.79

213 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE93464 $253.0993464 26 $88.9493464 TC $164.1593503 $89.3093505 $707.5793505 26 $218.0293505 TC $489.5593530 26 $206.0993531 26 $428.0893532 26 $524.9893533 26 $350.7193561 26 $47.0093562 26 $37.9693563 $57.8593564 $60.3893565 $44.8393566 $155.1193567 $130.5293568 $140.2893571 26 $76.6593572 26 $62.1993580 $962.4793581 $1,306.3193582 $653.7093583 $730.3593590 $1,102.7593591 $908.6093592 $402.4193600 26 $117.5193602 26 $115.3493603 26 $115.7093609 26 $275.8793610 26 $162.7093612 26 $161.2593613 $291.7893615 26 $39.0593616 26 $61.1093618 26 $219.1093619 26 $387.5993620 26 $622.9693621 26 $115.7093622 26 $171.0293623 26 $157.2893624 26 $238.99

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE93631 26 $389.7693640 26 $177.1693641 26 $309.8693642 $337.7093642 26 $254.1893642 TC $83.5293644 $202.1193644 26 $148.9693644 TC $53.1593650 $582.4793653 $823.6393654 $1,102.3993655 $419.4193656 $1,105.6493657 $418.6893660 $161.6293660 26 $95.4593660 TC $66.1793662 26 $145.3593668 $17.7293701 $25.6793702 $128.7193724 $282.0293724 26 $248.0393724 TC $33.9993740 $8.3293750 $55.6893770 $8.3293784 $54.2393786 $30.0193788 $5.4293790 $19.1693793 $12.2993797 $16.6393798 $25.6793880 $204.6493880 26 $40.1393880 TC $164.5193882 $130.1693882 26 $24.2293882 TC $105.9493886 $275.8793886 26 $47.3693886 TC $228.50

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE93888 $138.4893888 26 $25.6793888 TC $112.8193890 $281.2993890 26 $51.7093890 TC $229.5993892 $173.1993892 26 $60.3893892 TC $112.8193893 $173.5593893 26 $60.7493893 TC $112.8193922 $87.5093922 26 $12.6593922 TC $75.2093923 $135.5893923 26 $22.0693923 TC $113.5393924 $167.7693924 26 $24.5993924 TC $143.1893925 $260.3293925 26 $39.0593925 TC $221.2793926 $136.6793926 26 $24.2293926 TC $112.4493930 $208.6293930 26 $39.4193930 TC $169.2193931 $130.1693931 26 $24.2293931 TC $105.9493970 $198.1393970 26 $34.3593970 TC $163.7993971 $122.9393971 26 $22.4293971 TC $100.5193975 $282.7493975 26 $57.4993975 TC $225.2593976 $152.5893976 26 $39.77

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE93976 TC $112.8193978 $191.2693978 26 $39.0593978 TC $152.2293979 $121.8593979 26 $24.2293979 TC $97.6293980 $126.5593980 26 $62.5593980 TC $64.0093981 $77.0193981 26 $21.6993981 TC $55.3293990 $136.6793990 26 $23.8693990 TC $112.8194002 $92.9294003 $66.5394004 $49.1794005 $92.9294010 $35.7994010 26 $8.3294010 TC $27.4894011 $87.5094012 $142.0994013 $19.5294014 $56.7694015 $31.0994016 $25.6794060 $60.3894060 26 $13.0294060 TC $47.3694070 $60.3894070 26 $28.9294070 TC $31.4694150 $25.6794150 26 $3.9894150 TC $22.0694200 $27.8494200 26 $5.4294200 TC $22.4294250 $27.8494250 26 $5.4294250 TC $22.42

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE94375 $40.1394375 26 $14.8294375 TC $25.3194400 $57.8594400 26 $19.8994400 TC $37.9694450 $73.7694450 26 $20.2594450 TC $53.5194452 $55.6894452 26 $14.4694452 TC $41.2294453 $77.0194453 26 $19.1694453 TC $57.8594610 $56.0494617 $95.4594617 26 $33.9994617 TC $61.4694618 $34.3594618 26 $23.1494618 TC $11.2194621 $162.7094621 26 $69.7894621 TC $92.9294640 $18.4494644 $50.6294645 $16.9994660 $64.3694662 $36.1694664 $17.3594667 $25.3194668 $32.9094669 $32.1894680 $56.4094680 26 $12.6594680 TC $43.7594681 $55.6894681 26 $10.4994681 TC $45.5694690 $53.5194690 26 $3.9894690 TC $49.9094726 $54.60

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE94726 26 $12.6594726 TC $42.3094727 $44.1194727 26 $12.6594727 TC $31.8294728 $41.2294728 26 $12.6594728 TC $28.5694729 $56.0494729 26 $9.0494729 TC $47.0094750 $86.4194750 26 $10.8594750 TC $75.5794760 $2.5394761 $4.3494762 $25.6794770 $7.5994780 $52.0694781 $20.6195004 $4.3495012 $20.6195017 $8.3295018 $22.0695024 $8.3295027 $4.7095028 $13.3895044 $5.7895052 $6.8795056 $47.0095060 $35.7995065 $26.7695070 $32.1895071 $37.9695076 $122.9395079 $86.7795115 $9.4095117 $10.8595144 $14.8295145 $29.2995146 $54.2395147 $56.0495148 $80.6395149 $107.38

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE95165 $14.4695170 $10.8595180 $140.2895249 $56.0495250 $153.3095251 $35.7995782 $923.0695782 26 $127.9995782 TC $795.0795783 $982.7195783 26 $139.2095783 TC $843.5195803 $146.0795803 26 $44.4795803 TC $101.6095805 $427.0095805 26 $59.6695805 TC $367.3495807 $437.1295807 26 $62.5595807 TC $374.5795808 $682.9895808 26 $89.3095808 TC $593.6895810 $624.0595810 26 $122.9395810 TC $501.1295811 $654.0695811 26 $127.6395811 TC $526.4395812 $330.8395812 26 $58.5795812 TC $272.2595813 $410.7395813 26 $87.8695813 TC $322.8795816 $369.8795816 26 $58.5795816 TC $311.3095819 $434.9595819 26 $58.5795819 TC $376.3895822 $392.6595822 26 $58.93

220 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE95822 TC $333.7295824 26 $40.1395827 $618.9995827 26 $57.1395827 TC $561.8695829 $1,929.6495829 26 $340.9595829 TC $1,588.6995830 $394.4695831 $32.9095832 $32.1895833 $43.0395834 $56.0495836 $108.1195851 $21.3395852 $19.1695857 $54.9695860 $123.2995860 26 $52.4395860 TC $70.8795861 $175.3695861 26 $83.5295861 TC $91.8495863 $220.5595863 26 $101.2495863 TC $119.3195864 $253.4595864 26 $108.1195864 TC $145.3595865 $152.2295865 26 $84.6095865 TC $67.6195866 $139.5695866 26 $68.7095866 TC $70.8795867 $107.3895867 26 $42.6695867 TC $64.7295868 $141.0195868 26 $64.3695868 TC $76.6595869 $96.1795869 26 $20.2595869 TC $75.93

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE95870 $92.9295870 26 $20.2595870 TC $72.6795872 $200.3095872 26 $155.8395872 TC $44.4795873 $77.0195873 26 $20.6195873 TC $56.4095874 $78.4695874 26 $20.2595874 TC $58.2195875 $134.5095875 26 $60.0295875 TC $74.4895885 $62.1995885 26 $19.1695885 TC $43.0395886 $96.1795886 26 $47.0095886 TC $49.1795887 $83.5295887 26 $38.3395887 TC $45.1995905 $64.7295905 26 $2.8995905 TC $62.1995907 $97.2695907 26 $54.2395907 TC $43.0395908 $126.1895908 26 $68.7095908 TC $57.4995909 $150.4195909 26 $81.7195909 TC $68.7095910 $197.4195910 26 $109.1995910 TC $88.2295911 $237.1895911 26 $136.3195911 TC $100.8795912 $266.4795912 26 $162.34

222 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE95912 TC $104.1395913 $307.6995913 26 $192.3595913 TC $115.3495921 $84.6095921 26 $45.9295921 TC $38.6995922 $96.5495922 26 $48.4595922 TC $48.0995923 $130.5295923 26 $46.2895923 TC $84.2495924 $151.4995924 26 $89.6795924 TC $61.8395925 $134.1495925 26 $28.2095925 TC $105.9495926 $129.8095926 26 $27.8495926 TC $101.9695927 $134.1495927 26 $27.4895927 TC $106.6695928 $222.7295928 26 $80.6395928 TC $142.0995929 $228.1495929 26 $80.9995929 TC $147.1595930 $69.7895930 26 $19.1695930 TC $50.6295933 $82.4495933 26 $31.8295933 TC $50.6295937 $88.9495937 26 $34.7195937 TC $54.2395938 $352.5295938 26 $46.6495938 TC $305.8895939 $523.54

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE95939 26 $121.8595939 TC $401.6995940 $32.9095950 $297.2095950 26 $79.5495950 TC $217.6695951 26 $325.0495953 $450.8695953 26 $166.3295953 TC $284.5595954 $406.3995954 26 $117.1495954 TC $289.2595955 $214.0495955 26 $54.9695955 TC $159.0995956 $1,483.1195956 26 $192.7195956 TC $1,290.4095957 $273.3495957 26 $104.8595957 TC $168.4995958 $584.2895958 26 $228.5095958 TC $355.7795961 $309.4995961 26 $163.0695961 TC $146.4395962 $265.7595962 26 $174.9995962 TC $90.7595965 26 $429.5395966 26 $217.3095967 26 $189.8295970 $19.1695971 $50.9895972 $57.1395976 $40.8695977 $54.2395980 $44.8395981 $34.3595982 $54.6095983 $50.9895984 $44.47

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE95990 $94.3795991 $118.2395992 $44.4796000 $96.1796001 $124.7496002 $22.4296003 $17.7296004 $115.3496020 26 $166.3296040 $46.6496105 $105.5796110 $10.1296112 $136.3196113 $60.7496116 $96.1796121 $82.4496125 $111.7296127 $5.4296130 $117.5196131 $89.6796132 $132.6996133 $101.2496136 $47.7396137 $44.1196138 $39.0596139 $39.0596146 $2.1796150 $23.1496151 $22.7896152 $20.9796153 $5.0696154 $20.6196160 $3.2596161 $3.2596360 $38.3396361 $13.7496365 $72.3196366 $22.0696367 $31.4696368 $21.3396369 $169.2196370 $15.9196371 $66.5396372 $16.99

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE96373 $19.1696374 $39.4196375 $16.9996377 $20.6196401 $80.2796402 $31.4696405 $83.1696406 $124.0196409 $109.1996411 $59.3096413 $142.0996415 $30.7396416 $142.8296417 $68.7096420 $105.2196422 $173.5596423 $80.2796425 $183.6796440 $848.2296446 $205.0096450 $183.3196521 $147.8896522 $121.1296523 $27.4896542 $135.2296567 $126.5596570 $52.0696571 $29.2996573 $205.7396574 $261.4196900 $22.0696902 $22.0696904 $65.4496910 $116.7896912 $99.0796913 $141.0196920 $166.6896921 $182.9596922 $248.0396931 $173.1996932 $17.3596933 $47.0096934 $98.3496935 $45.56

226 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE96936 $44.8397010 $6.5197022 $18.4497032 $15.1997035 $14.1097110 $31.0997112 $35.4397113 $39.4197116 $30.7397150 $18.8097151 $27.4697152 $20.3297153 $9.3697154 $2.3597155 $27.4697161 $86.0597162 $86.0597163 $86.0597164 $58.5797165 $92.5697166 $92.5697167 $92.5697168 $63.6397530 $40.4997537 $33.2697597 $90.7597598 $28.5697605 $44.4797606 $52.4397761 $41.5897802 $37.6097803 $32.5497804 $17.3597810 $36.5297811 $27.8497813 $40.1397814 $32.5498925 $31.8298926 $45.5698927 $60.0298928 $72.6798929 $87.1498940 $41.7498941 $58.06

227 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE98942 $75.5998966 $14.1098966 $14.1098967 $27.1298967 $27.1298968 $39.7798968 $39.7799170 $160.1799173 $2.8999174 $5.7899175 $26.3999177 $4.7099177 $4.7099183 $108.8399184 $223.8099188 $26.3499195 $102.3299201 $45.9299202 $76.2999203 $108.1199204 $163.7999205 $206.0999211 $23.1499212 $45.1999213 $74.4899214 $108.8399215 $145.7199217 $73.0399218 $99.0799219 $135.2299220 $185.1299221 $100.1599222 $135.9599223 $201.3999224 $39.4199225 $72.6799226 $104.4999231 $39.0599232 $72.3199233 $103.7799234 $132.3399235 $168.4999236 $216.9399238 $73.03

228 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE99239 $107.0299281 $20.9799282 $40.8699283 $61.1099284 $116.0699285 $171.0299291 $276.2399292 $121.8599304 $89.6799305 $130.1699306 $166.6899307 $44.1199308 $68.7099309 $91.4799310 $135.5899315 $73.4099316 $105.5799318 $95.8199324 $55.3299325 $79.9099326 $138.8499327 $186.2099328 $219.4799334 $60.3899335 $95.0999336 $135.2299337 $193.8099341 $55.3299342 $79.5499343 $129.8099344 $181.8699345 $221.2799347 $55.3299348 $83.8899349 $129.0899350 $178.6199354 $130.1699355 $99.0799356 $92.2099357 $92.5699360 $61.4699366 $43.0399374 $69.7899375 $104.49

229 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE99377 $69.7899378 $104.4999379 $69.7899380 $104.4999381 $111.7299382 $116.7899383 $121.4899384 $137.0399385 $132.6999386 $154.0299387 $166.6899391 $100.5199392 $107.3899393 $107.0299394 $117.1499395 $119.6899396 $127.6399397 $137.0399406 $14.8299407 $28.2099408 $35.7999409 $69.0699460 $95.8199461 $91.8499462 $41.9499463 $111.0099464 $74.8499465 $146.0799466 $238.9999467 $119.3199468 $920.5399469 $398.0899471 $796.8799472 $406.7599475 $560.7899476 $347.1099477 $348.9099478 $137.0399479 $124.7499480 $119.3199483 $260.6899487 $92.2099489 $46.2899490 $41.58

230 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEE99491 $82.8099495 $164.8799496 $232.480373T $11.24G0027 $7.23G0101 $39.05G0102 $22.78G0103 $20.44G0104 $174.27G0105 $323.96G0106 $232.12G0106 26 $51.34G0106 TC $180.78G0108 $55.68G0109 $15.55G0117 $56.76G0118 $42.30G0120 $231.40G0120 26 $50.62G0120 TC $180.78G0121 $324.32G0122 $295.39G0122 26 $49.90G0122 TC $245.50G0123 $22.51G0124 $32.18G0127 $24.59G0128 $7.95G0130 $35.43G0130 26 $11.21G0130 TC $24.22G0141 $32.18G0143 $27.05G0144 $43.97G0145 $29.44G0147 $14.99G0148 $31.94G0166 $116.06G0168 $96.90G0179 $41.58G0180 $53.51G0181 $107.74G0182 $108.11G0237 $9.76

231 of 238

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEEG0238 $10.12G0239 $12.65G0245 $66.89G0246 $39.77G0247 $78.10G0248 $72.67G0249 $73.40G0250 $9.40G0252 26 $75.93G0268 $49.17G0270 $32.54G0271 $17.35G0277 $111.72G0278 $13.38G0279 $55.68G0279 26 $30.37G0279 TC $25.31G0281 $14.46G0288 $34.71G0289 $85.69G0296 $28.92G0297 $240.80G0297 26 $51.70G0297 TC $189.09G0306 $8.63G0307 $7.18G0328 $19.64G0329 $11.21G0337 $72.67G0341 $2,137.53G0342 $704.31G0343 $1,162.77G0365 $125.10G0365 26 $12.29G0365 TC $112.81G0372 $9.04G0396 $35.79G0397 $66.89G0402 $167.04G0403 $16.99G0404 $8.68G0405 $8.68G0406 $38.69G0407 $71.95

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEEG0408 $103.41G0409 $16.63G0412 $718.78G0413 $1,058.64G0414 $996.82G0415 $1,363.80G0416 $385.78G0416 26 $184.76G0416 TC $201.03G0425 $99.43G0426 $135.22G0427 $201.03G0429 $98.71G0432 $19.57G0433 $18.29G0435 $13.32G0438 $172.46G0439 $116.78G0455 $129.08G0471 $5.00G0472 $46.35G0476 $38.99G0480 $114.43G0481 $156.59G0482 $198.74G0483 $246.92G0499 $31.41G0500 $58.57G0659 $64.65G6001 $83.88G6001 26 $31.82G6001 TC $52.06G6002 $77.37G6002 26 $20.97G6002 TC $56.40G6003 $199.94G6004 $146.43G6005 $146.43G6006 $146.07G6007 $276.95G6008 $202.11G6009 $201.03G6010 $201.03G6011 $273.34

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEEG6012 $267.91G6013 $268.28G6014 $268.28G6015 $363.00G6016 $362.64G9143 $134.13H1000 $84.09H1001 $56.06H1002 $56.06H1003 $56.06H1004 $56.06J0129 $51.61J0130 $1,429.07J0132 $1.45J0171 $0.74J0178 $963.54J0180 $178.17J0207 $979.75J0221 $166.20J0256 $4.55J0257 $4.70J0278 $1.18J0280 $7.02J0290 $1.00J0295 $2.62J0348 $0.56J0360 $2.58J0401 $5.47J0456 $2.76J0461 $0.07J0470 $54.42J0475 $169.75J0476 $44.35J0480 $3,677.61J0485 $3.79J0490 $44.16J0500 $69.65J0515 $18.67J0558 $10.96J0561 $13.85J0583 $0.80J0585 $6.14J0586 $8.53J0587 $12.00

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEEJ0588 $5.08J0592 $4.15J0594 $10.82J0595 $2.62J0597 $48.92J0598 $54.02J0600 $5,594.42J0840 $3,291.27J7321 $79.91J7323 $141.03J7324 $146.91J7325 $11.86J7327 $791.24J9030 $2.82P3000 $14.99P3001 $32.18P9603 $0.32P9604 $4.67Q0035 $20.25Q0035 26 $8.68Q0035 TC $11.57Q0091 $43.75Q0092 $24.59Q0111 $14.99Q0138 $1.01Q0139 $1.01Q0162 $0.03Q0163 $0.26Q0166 $2.87Q0510 $60.28Q0511 $28.94Q0512 $19.29Q0513 $39.79Q0514 $79.56Q2035 $18.24Q3014 $31.17Q4001 $51.47Q4002 $194.51Q4003 $36.99Q4004 $127.96Q4005 $13.63Q4006 $30.71Q4007 $6.81Q4008 $15.35

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEEQ4009 $9.09Q4010 $20.49Q4011 $4.55Q4012 $10.22Q4013 $16.54Q4014 $27.94Q4015 $8.27Q4016 $13.97Q4017 $9.59Q4018 $15.29Q4019 $4.77Q4020 $7.65Q4021 $7.07Q4022 $12.81Q4023 $3.57Q4024 $6.36Q4025 $39.76Q4026 $124.09Q4027 $19.88Q4028 $62.03Q4029 $30.40Q4030 $79.99Q4031 $15.19Q4032 $40.00Q4033 $28.36Q4034 $70.50Q4035 $14.19Q4036 $35.26Q4037 $17.29Q4038 $43.32Q4039 $8.66Q4040 $21.68Q4041 $21.03Q4042 $35.88Q4043 $10.50Q4044 $17.96Q4045 $12.20Q4046 $19.61Q4047 $6.08Q4048 $9.83Q4049 $2.24Q4101 $30.49Q4102 $11.40Q4106 $32.82

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEEQ4132 $135.00Q4133 $135.17Q4186 $159.86Q4195 $75.87Q4196 $59.81Q9958 $0.08Q9960 $0.22R0070 $71.64R0075 $71.64S0302 $127.51S0390 $20.28S2083 $104.20S5497 $7.02S9326 $54.57S9327 $70.15S9330 $54.57S9331 $70.15S9338 $70.15S9339 $54.57S9364 $257.14S9373 $70.15S9497 $93.84S9500 $70.38S9501 $77.52S9502 $77.52S9503 $77.52S9504 $93.84T1001 $16.00T1002 $16.72T1003 $13.62T1004 $10.48T1015 $111.55T1021 $17.77T1025 $336.65T1030 $66.87T1031 $54.47V2020 $24.93V2025 $15.60V2104 $7.02V2105 $4.67V2111 $2.74V2204 $16.39V2299 $17.14V2304 $22.29

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ND MEDICAID PROFESSIONAL SERVICES FEE SCHEDULEas of 07/01/2019

Inclusion or exclusion of a procedure code, supply, product, or service does not imply Medicaid coverage, reimbursement, or lack thereof.

CODE MODIFIERMEDICAID

FEEV2430 $34.30V2624 $94.21V2625 $562.52V2626 $243.17V2628 $480.72V2710 $72.46V2715 $3.11V2718 $12.11V2744 $7.27V2745 $1.95V2760 $2.74V2780 $2.34V2784 $7.79V2799 $3.49

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