Standard Rate Schedule: Non-Medicaid Clinician-Based 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist
112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant Rev. 04/01/2022
Service
90785 ‐ INTERACTIVE COMPLEXITY 90791 ‐ Psychiatric Diagnostic Evaluation 90791SR ‐ In‐Home Psychiatric Diagnostic Evaluation 90792 ‐ PSYCHIATRIC DIAGNOSTIC EVAL W/ MED 90832 ‐ PSYCHOTHERAPY 30 MN 90832SR ‐ IN‐HOME PSYCHOTHERAPY 60 MN 90833 ‐ PSYCHOTHERAPY 30 MIN ADD ON TO E&M 90834 ‐ PSYCHOTHERAPY 45 MN 90834SR ‐ IN‐HOME PSYCHOTHERAPY 60 MN 90836 ‐ PSYCHOTHERAPY 45 MIN ADD ON TO E&M 90837 ‐ PSYCHOTHERAPY 60 MN 90837SR ‐ IN‐HOME PSYCHOTHERAPY 60 MN 90838 ‐ PSYCHOTHERAPY 60 MIN ADD ON TO E&M 90839 ‐ PSYCHOTHER FOR CRISIS 60 MIN 90840 ‐ PSYCHOTHER FOR CRISIS ADDÆL 30 MN 90846 ‐ FAMILY THER W/O PT 90846SR ‐ In‐home Family Ther W/O PT 90847 ‐ FAMILY THER W/ PT 90847SR ‐ In‐home Family Ther W/ PT 90849 ‐ MULTI‐FAM GROUP 90853 ‐ GROUP THER 96110 ‐ DEVEL TST LMT 96112 ‐ DEVEL TST EXT 96113 ‐ add on DEVEL TST EXT 96116 ‐ NEUROBEHAV EXAM 96121 ‐ add on NEUROBEHAV EXAM 96130 ‐ PSYCH TESTING CLINICAL PSYCH 96131 ‐ add on PSYCH TESTING CLINICAL PSYCH 96132 ‐ NEUROPSYCH TST‐ CLIN PSYCH 96133 ‐ add on NEUROPSYCH TST‐ CLIN PSYCH 96136 ‐ PSYCH OR NEUROPSYCH TESTING CLINICAL PSYCH TST ADMIN AND SCORING 96137 ‐ add on PSYCH OR NEUROPSYCH TESTING CLINICAL PSYCH TST ADMIN AND SCORING 96372 ‐ Therapeutic prophylactic or diagnostic injection 99202 ‐ OP Visit New Pat, straightforward, 15‐29 minutes 99203 ‐ OP Visit New Pat, low level, 30‐44 minutes 99204 ‐ OP Visit New Pat, moderate, 45‐59 minutes 99205 ‐ OP Visit New Pat, high level, 60‐74 minutes
Effective Date
End Date
ALL
101
1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
1/1/2022
6/30/2022
1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
3.96 135.94 149.59 153.30 55.48 63.74 34.91 86.07 98.11 51.72 108.51 132.48 86.59 120.28 105.47 68.71 136.88 102.88 136.88 36.00 36.00 8.75 132.53 66.27 118.32 118.32 107.58 107.58 140.58 140.58
109
110
$ 3.96 $ 2.97 $ $ 120.39 $ 89.04 $ $ 132.48 $ 132.48 $ $ $
47.24 $ 63.74 $
34.18 $ 63.74 $
$ $
62.85 $ 98.11 $
45.89 $ 98.11 $
$ 94.42 $ 69.57 $ $ 132.48 $ 132.48 $
112
128
3.37 $ 3.84 $ 114.80 $ 116.63 $ 132.48 $ 132.48 $ $ 129.56 39.40 $ 46.41 $ 63.74 $ 63.74 $ $ 29.67 72.41 $ 72.41 $ 98.11 $ 98.11 $ $ 50.02 91.48 $ 91.48 $ 132.48 $ 132.48 $ $ 83.84 101.49 $ 116.52 $ 89.65 $ 97.31 $ 70.09 $ 70.09 $ 136.88 $ 136.88 $ 86.70 $ 86.70 $ 136.88 $ 136.88 $ 36.00 $ 36.00 $ 36.00 $ 36.00 $ $ 7.30 $ $ $ $ $ $ $ $ $
120.28 105.47 67.24 136.88 84.70 136.88 36.00 36.00 8.58 116.16 53.20 93.07 93.07 101.00 83.94 113.03 104.95
$
53.79 $
41.97
$
31.48
6/30/2022
$
53.79 $
41.97
$
31.48
6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
$ $ $ $ $
$ 14.48 $ 50.81 $ 75.86 $ 120.39 $ 153.51
129
210
2.97 $ 2.97 $ 89.04 $ 89.04 $ 132.48 $ 132.48 $ $ 34.18 $ 34.18 $ 63.74 $ 63.74 $ $ 45.89 $ 45.89 $ 98.11 $ 98.11 $ $ 69.57 $ 69.57 $ 132.48 $ 132.48 $ $ 88.96 $ 88.96 $ 79.10 $ 79.10 $ 49.17 $ 49.17 $ 136.88 $ 136.88 $ 62.28 $ 62.28 $ 136.88 $ 136.88 $ 36.00 $ 36.00 $ 36.00 $ 36.00 $ 6.43 $ 87.12 39.90 69.82 69.82 75.75 62.96 84.77 78.71
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
17.04 52.54 84.36 124.27 158.41
$ 88.96 $ $ 79.10 $ $ 49.17 $ $ 136.88 $ $ 62.28 $ $ 136.88 $ $ 36.00 $ $ 36.00 $
111
$ $ $ $ $
3.37 114.80 132.48 129.56 46.41 63.74 29.67 72.41 98.11 48.21 91.48 132.48 77.85 120.28 65.41 70.09 136.88 86.70 136.88 36.00 36.00 8.75
17.04 52.54 78.36 129.27 158.41
Standard Rate Schedule: Non-Medicaid Clinician-Based 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist
112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant Rev. 04/01/2022
Service
Effective Date
End Date
ALL
101
99211 ‐ OP Visit Est Pat, presenting problem minimal 99212 ‐ OP Visit Est Pat, straightforward, 10‐19 minutes 99213 ‐ OP Visit Est Pat, low level, 20‐29 minutes 99214 ‐ OP Visit Est Pat, moderate, 30‐39 minutes 99215 ‐ OP Visit Est Pat, high level, 40‐54 minutes
1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
$ $ $ $ $
11.82 28.50 70.00 100.00 109.00
99406 ‐ smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes, up to 10 minutes
1/1/2022
6/30/2022
$
109
110
111
112
128
129
210
$ 11.82 $ 28.48 $ 58.75 $ 84.25 $ 105.58
$ $ $ $ $
11.82 28.50 58.75 84.25 109.00
11.93
$
11.93
$
11.93
99407 ‐ smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes 99417 ‐ Prolonged Office or other OP (15 min) 99421 ‐ Online Digital E/M Service, 5‐10 min 99422 ‐ Online Digital E/M Service, 11‐20 min 99423 ‐ Online Digital E/M Service, 21 or more min
1/1/2022
6/30/2022
$
23.05
$
23.05
$
23.05
1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 6/30/2022 6/30/2022
$ $ $ $
77.03 12.76 25.47 41.16
$ $ $ $
77.03 12.76 25.47 41.16
$ $ $ $
77.03 12.76 25.47 41.16
99441 ‐ Telephone Evaluation and Management Service ‐ 5‐10 min
1/1/2022
6/30/2022
$
11.89
$
11.89
$
11.89
1/1/2022
6/30/2022
$
23.16
$
23.16
$
23.16
1/1/2022
6/30/2022
$
33.95
$
33.95
$
33.95
1/1/2022
6/30/2022
$
15.20
1/1/2022
6/30/2022
$
30.69
1/1/2022
6/30/2022
$
45.89
1/1/2022
6/30/2022
$
61.15
99442 ‐ Telephone Evaluation and Management Service ‐ 11‐20 min 99443 ‐ Telephone Evaluation and Management Service ‐ 21‐30 min 99446 ‐ Interprofessional Tele/Internet/EHR Consultation, 5‐10 min 99447 ‐ Interprofessional Tele/Internet/EHR Consultation, 11‐20 min 99448 ‐ Interprofessional Tele/Internet/EHR Consultation, 21‐30 min 99449 ‐ Interprofessional Tele/Internet/EHR Consultation, 31 or more min