Standard Rate Schedule: Non‐Medicaid 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist rev. 11/24/21
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
112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant
Effective Date 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
End Date 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
ALL
101 $ 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
109 110 111 112 $ 3.96 $ 2.97 $ 3.37 $ 3.84 $ 120.39 $ 89.04 $ 114.80 $ 116.63 $ 132.48 $ 132.48 $ 132.48 $ 132.48 $ 129.56 $ 47.24 $ 34.18 $ 39.40 $ 46.41 $ 63.74 $ 63.74 $ 63.74 $ 63.74 $ 29.67 $ 62.85 $ 45.89 $ 72.41 $ 72.41 $ 98.11 $ 98.11 $ 98.11 $ 98.11 $ 50.02 $ 94.42 $ 69.57 $ 91.48 $ 91.48 $ 132.48 $ 132.48 $ 132.48 $ 132.48 $ 83.84 $ 120.28 $ 88.96 $ 101.49 $ 116.52 $ 105.47 $ 79.10 $ 89.65 $ 97.31 $ 67.24 $ 49.17 $ 70.09 $ 70.09 $ 136.88 $ 136.88 $ 136.88 $ 136.88 $ 84.70 $ 62.28 $ 86.70 $ 86.70 $ 136.88 $ 136.88 $ 136.88 $ 136.88 $ 36.00 $ 36.00 $ 36.00 $ 36.00 $ 36.00 $ 36.00 $ 36.00 $ 36.00 $ 8.58 $ 7.30 $ 116.16 $ 53.20 $ 93.07 $ 93.07 $ 101.00 $ 83.94 $ 113.03 $ 104.95
1/1/2022
6/30/2022
$ 53.79 $ 41.97
$ 31.48
1/1/2022
6/30/2022
$ 53.79 $ 41.97
$ 31.48
1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 6/30/2022 6/30/2022
$ 17.04 $ 52.54 $ 84.36 $ 124.27
$ 14.48 $ 50.81 $ 75.86 $ 120.39
128 129 210 $ 2.97 $ 2.97 $ 3.37 $ 89.04 $ 89.04 $ 114.80 $ 132.48 $ 132.48 $ 132.48 $ 129.56 $ 34.18 $ 34.18 $ 46.41 $ 63.74 $ 63.74 $ 63.74 $ 29.67 $ 45.89 $ 45.89 $ 72.41 $ 98.11 $ 98.11 $ 98.11 $ 48.21 $ 69.57 $ 69.57 $ 91.48 $ 132.48 $ 132.48 $ 132.48 $ 77.85 $ 88.96 $ 88.96 $ 120.28 $ 79.10 $ 79.10 $ 65.41 $ 49.17 $ 49.17 $ 70.09 $ 136.88 $ 136.88 $ 136.88 $ 62.28 $ 62.28 $ 86.70 $ 136.88 $ 136.88 $ 136.88 $ 36.00 $ 36.00 $ 36.00 $ 36.00 $ 36.00 $ 36.00 $ 6.43 $ 8.75 $ 87.12 $ 39.90 $ 69.82 $ 69.82 $ 75.75 $ 62.96 $ 84.77 $ 78.71
$ 17.04 $ 52.54 $ 78.36 $ 129.27
Standard Rate Schedule: Non‐Medicaid 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist rev. 11/24/21
Service Effective Date 99205 ‐ OP Visit New Pat, high level, 60‐74 minutes 1/1/2022 99211 ‐ OP Visit Est Pat, presenting problem minimal 1/1/2022 99212 ‐ OP Visit Est Pat, straightforward, 10‐19 minutes 1/1/2022 99213 ‐ OP Visit Est Pat, low level, 20‐29 minutes 1/1/2022 99214 ‐ OP Visit Est Pat, moderate, 30‐39 minutes 1/1/2022 99215 ‐ OP Visit Est Pat, high level, 40‐54 minutes 1/1/2022 99406 ‐ smoking and tobacco use cessation counseling visit; 1/1/2022 intermediate, greater than 3 minutes, up to 10 minutes 99407 ‐ smoking and tobacco use cessation counseling visit; 1/1/2022 intensive, greater than 10 minutes 99417 ‐ Prolonged Office or other OP (15 min) 1/1/2022 99421 ‐ Online Digital E/M Service, 5‐10 min 1/1/2022 99422 ‐ Online Digital E/M Service, 11‐20 min 1/1/2022 99423 ‐ Online Digital E/M Service, 21 or more min 1/1/2022 99441 ‐ Telephone Evaluation and Management Service ‐ 5‐ 1/1/2022 10 min 99442 ‐ Telephone Evaluation and Management Service ‐ 11‐ 1/1/2022 20 min 99443 ‐ Telephone Evaluation and Management Service ‐ 21‐ 1/1/2022 30 min 99446 ‐ Interprofessional Tele/Internet/EHR Consultation, 5‐ 1/1/2022 10 min 99447 ‐ Interprofessional Tele/Internet/EHR Consultation, 11‐ 1/1/2022 20 min 99448 ‐ Interprofessional Tele/Internet/EHR Consultation, 21‐ 1/1/2022 30 min 99449 ‐ Interprofessional Tele/Internet/EHR Consultation, 31 1/1/2022 or more min H0010 ‐ DETOX‐NON‐HSP‐MED 1/1/2022 H0012HB ‐ Community Residential Tx‐Adult 1/1/2022 H0013 ‐ SA Med Mon Community Residential Tx 1/1/2022 H0014 ‐ AMBULATORY DETOX 1/1/2022 H0015 ‐ SA IOP 1/1/2022 H0020 ‐ Outpatient Opioid Treatment 1/1/2022 H0038 ‐ Peer Support Services (PSS) ‐ individual 1/1/2022 H0038HQ ‐ Peer Support Services (PSS) ‐ group 1/1/2022 H0040 ‐ ACTT 1/1/2022 H004022 ‐ ACTT > 4 events per month 1/1/2022
112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant
End Date 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
ALL
101 $ 158.41 $ 11.82 $ 28.50 $ 70.00 $ 100.00 $ 109.00
109
110
111
112 $ 153.51 $ 11.82 $ 28.48 $ 58.75 $ 84.25 $ 105.58
128
129
210 $ 158.41 $ 11.82 $ 28.50 $ 58.75 $ 84.25 $ 109.00
6/30/2022
$ 11.93
$ 11.93
$ 11.93
6/30/2022
$ 23.05
$ 23.05
$ 23.05
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
6/30/2022
$ 11.89
$ 11.89
$ 11.89
6/30/2022
$ 23.16
$ 23.16
$ 23.16
6/30/2022
$ 33.95
$ 33.95
$ 33.95
6/30/2022
$ 15.20
6/30/2022
$ 30.69
6/30/2022
$ 45.89
6/30/2022
$ 61.15
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
$ 325.58 $ 155.81 $ 241.81 $ 21.25 $ 131.56 $ 16.60 $ 13.26 $ 2.88 $ 304.18 $ 0.01
Standard Rate Schedule: Non‐Medicaid 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist rev. 11/24/21
Service
Effective Date H2011 ‐ CRISIS SERVICES 1/1/2022 H2012HA ‐ DAY TREATMENT CHILD 1/1/2022 H2014U1 ‐ DEVELOPMENTAL TX PARA GROUP 1/1/2022 H2015HTHF ‐ CST ‐ SA Professional ‐ Community Support 1/1/2022 H2015HTHM ‐ CST ‐ Paraprofessional ‐ Community Support 1/1/2022 H2015HTHN ‐ CST ‐ QP/AP ‐ Community Support Team 1/1/2022 H2015HTHO ‐ CST ‐ Team Lead ‐ Community Support Team 1/1/2022 H2015HTU1 ‐ CST ‐ PSS ‐ Community Support Team 1/1/2022 H2017 ‐ PSYCHOSOCIAL REHAB 1/1/2022 H2034 ‐ SA Half‐way House 1/1/2022 H2035 ‐ SA Comprehensive Outpatient Trt Prog 1/1/2022 Q3014GT ‐ TELEHEALTH ORIG SITE FEE 1/1/2022 S9484 ‐ FAC BASED CRISIS HR 1/1/2022 T1023 ‐ DIAGNOSTIC‐ASSESSMENT 1/1/2022 YA125 ‐ Hourly Respite(CMSED) 1/1/2022 YA213 ‐ Community Respite(CMSED) 1/1/2022 YA302 ‐ Community Guide‐State 1/1/2022 YA313 ‐ Crisis Respite 1/1/2022 YA323 ‐ ASSERTIVE ENGAGEMENT 1/1/2022 YA331 ‐ Jail Assessment 1/1/2022 YA332 ‐ Outpatient Commit followup 1/1/2022 YA334 ‐ Forensic Evaluation 1/1/2022 YA335 ‐ Jail Coordination 1/1/2022 YA336 ‐ Hospital dschg plg and tx 1/1/2022 YA341 ‐ Assertive Engagement 1/1/2022 YA355 ‐ DD DIVERSION EMERGENCY RESPITE 1/1/2022 YA368 ‐ ASSERTIVE ENGAGEMENT 1/1/2022 YA383 ‐ LONG TERM VOCATIONAL SUPPORT(GROUP) 1/1/2022 YA384 ‐ SAFETY & SUPERVISION PER DIEM 1/1/2022 YA385 ‐ SAFETY & SUPERVISION‐HOURLY 1/1/2022 YA389 ‐ LONG‐TERM VOCATIONAL SUPPORT ‐ I/DD 1/1/2022 YA390 ‐ SUPPORTED EMP IND ‐ I/DD 1/1/2022 YA393 ‐ Indiv Community Activity and Employment Transition 1/1/2022 YA394 ‐ Group Community Activity and Employment 1/1/2022 YM755 ‐ Family Living High 1/1/2022 YM812 ‐ MR/MI SUPERVISED LIV 2 RES 1/1/2022 YM813 ‐ MR/MI SUPERVISED LIV 3 RES 1/1/2022 YM814 ‐ MR/MI SUPERVISED LIV 4 RES 1/1/2022
112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant
End Date 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 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
ALL $ 90.00 $ 31.41 $ 2.01 $ 25.91 $ 25.91 $ 25.91 $ 25.91 $ 25.91 $ 2.69 $ 55.29 $ 45.35 $ 21.25 $ 30.00 $ 231.30 $ 5.00 $ 150.00 $ 150.00 $ 214.38 $ 15.00 $ 175.00 $ 22.65 $ 200.00 $ 12.82 $ 22.65 $ 15.00 $ 200.00 $ 15.00 $ 3.00 $ 60.00 $ 15.00 $ 11.21 $ 11.21 $ 9.65 $ 3.75 $ 100.00 $ 161.99 $ 116.15 $ 93.17
101
109
110
111
112
128
129
210
Standard Rate Schedule: Non‐Medicaid 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist rev. 11/24/21
Service Effective Date YM815 ‐ MR/MI SUPERVISED LIV 5 RES 1/1/2022 YM816 ‐ MR/MI SUPERVISED LIV 6 RES 1/1/2022 YM850 Residential Supports 1/1/2022 YP010 ‐ HOURLY RESPITE CARE DD 1/1/2022 YP011 ‐ RESPITE HOURLY DD GROUP 1/1/2022 YP020 ‐ INDIVIDUAL HABILITATION 1/1/2022 YP021 ‐ INDIVIDUAL HABILITATION ‐ GROUP 1/1/2022 YP610 Developmental Day 1/1/2022 YP620 ‐ MR/MI ADVP 1/1/2022 YP630 Supported Employment, Individual 1/1/2022 YP640 ‐ SUPPORTED EMP GROUP ‐ I/DD 1/1/2022 YP660 Day Activity 1/1/2022 YP710 ‐ APARTMENT LIVING 1/1/2022 YP720 ‐ SUPERVISED LIVING MODERATE 1/1/2022 YP740 ‐ FAMILY LIVING ‐ LOW INTENSITY 1/1/2022 YP750 ‐ Family Living Moderate 1/1/2022 YP760 ‐ GROUP LIVING LOW 1/1/2022 YP770 ‐ GROUP LIV MODERATE NON‐GRANT 1/1/2022 YP780 ‐ GROUP LIVING HIGH 1/1/2022 YP790 ‐ Detox ‐ Social Setting 1/1/2022 YP821 ‐ INPATIENT PSYCH 1/1/2022 YP830 ‐ ALCL &/or DRUG ASSESSMENT ‐ NON LIC 1/1/2022 YP831 ‐ SA INDIV TX > 30MIN ‐ NON LIC 1/1/2022 YP832 ‐ ALCOHOL & DRUG GROUP ‐ NON LIC 1/1/2022 YP833 ‐ BH Family Therapy w/ Client‐ Non Licensed SA 1/1/2022 YP834 ‐ BH FAMILY THERAPY W/O CLIENT‐ NON LICENSED SA 1/1/2022 YP835 ‐ ALCL & DRUG GROUP ‐ NON LIC 1/1/2022 YP836 ‐ MH ASSESSMENT BY NON‐LICENSED 1/1/2022 YP851 ‐ PSYCHIATRIST ADMIN 1/1/2022 YP852 ‐ PSYCHIATRIST CONSULT 1/1/2022
112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant
End Date 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
ALL $ 77.67 $ 68.83 $ 96.25 $ 5.00 $ 1.67 $ 4.46 $ 1.49 $ 4.74 $ 1.57 $ 14.22 $ 2.53 $ 3.75 $ 28.92 $ 55.11 $ 55.00 $ 77.50 $ 55.29 $ 75.48 $ 141.15 $ 118.42 $ 750.00 $ 22.00 $ 22.00 $ 8.11 $ 22.00 $ 22.00 $ 8.11 $ 13.87 $ 25.00 $ 35.00
101
109
110
111
112
128
129
210