Prairie View Inc. Standard Charges				 															
"1901 E First St, Newton, KS 67114-0467"																			
URL: https://prairieview.org/admissions/standard-charges																			
Machine Readable file: https://prairieview.org/uploads/media/480642318_PrairieView_standardcharges_1-2024.csv																			
POC/email:  Shely O'Laughlin  patientaccounts@pvi.org																			
"Rates as of:  January 1, 2024"																			
" File updated: January 23, 2024"																			
"Prairie View Inc. stopped providing inpatient services effective April 1, 2024 and is no longer a hospital facility"																			
*Rates shown are rates charged for services provided at any Prairie View location																			
																			
Service Code	Service Code Description	Code	Practitioner Category	Duration Range	Modifiers For Cross Reference	Type of Fee	Minutes per unit	Gross Charge	 Cigna Rate 	 United Healthcare Commercial 	 United Healthcare Medicare Advantage 	 Blue Cross Blue Shield 	 Humana Commercial 	 Humana Medicare Advantage 	 Aetna Commercial 	 Minimum Negotiated Charge 	 Maximum Negotiated Charge 	 Discounted Cash Price 	Comments
ADOLCLIN	ADOL Clinical Review/Coordination	(blank)				Fixed		$869.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
ADOLREPORT	ADOL Report	(blank)				Fixed		$428.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
ASAMEVAL	ASAM Assessment	H0001				Fixed		$193.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$189.00 	Outpatient
ATTENDCARE	Attendant Care	T1019			HE or HK	User Defined	15	$8.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$8.00 	Outpatient
AUTISMBTP	Autism-Adapt BH Treat by protocol	97153				User Defined	15	$14.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$13.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$11.23 	$11.23 	$13.00 	$14.00 	Outpatient
AUTISMBTPM	Autism-Adapt BH Treat w/ protocol mod	97155				User Defined	15	$29.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$28.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$15.14 	$15.14 	$28.00 	$28.00 	Outpatient
AUTISMFBT	Autism-Family Adapt BH Treat	97156				User Defined	15	$43.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$15.14 	$15.14 	$40.00 	$42.00 	Outpatient
AUTISMIDA	Autism-Behavior ID Assessment	97151				User Defined	15	$50.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$47.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$15.14 	$15.14 	$47.00 	$49.00 	Outpatient
AUTISMIDSA	Autism-Behavior ID Supporting Assessment	97152				User Defined	15	$38.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$11.23 	$11.23 	$35.00 	$37.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	DO			User Defined	30	$94.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$74.75 	$43.91 	$39.73 	 Not on Contract Fee Schedule 	$39.73 	$74.75 	$92.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	MD			User Defined	30	$94.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$74.75 	$43.91 	$39.73 	 Not on Contract Fee Schedule 	$39.73 	$74.75 	$92.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	APRN			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$56.70 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$56.70 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	LAC			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	LCMFT			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	LCP			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$53.30 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$53.30 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	LCPC			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	LCSW			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	LMFT			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	LMLP			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	LMLPT			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	LMSW			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	LP			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$65.00 	$37.64 	$33.87 	 Not on Contract Fee Schedule 	$33.87 	$65.00 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	LPC			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	LPT			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$65.00 	$37.64 	$33.87 	 Not on Contract Fee Schedule 	$33.87 	$65.00 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	LSCSW			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	MA			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	MS			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	MSN			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	MSW			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	PA			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	PHD			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$65.00 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$65.00 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	PSYD			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$65.00 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$65.00 	$84.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	ACW			User Defined	30	$41.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$40.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	BA			User Defined	30	$41.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$40.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	BS			User Defined	30	$41.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$40.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	CCM			User Defined	30	$41.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$40.00 	Outpatient
CASECONFW	Case Conference With Patient	99366	MHW			User Defined	30	$41.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$40.98 	$36.80 	 Not on Contract Fee Schedule 	$36.80 	$40.98 	$40.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99367	DO			User Defined	30	$94.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$58.08 	$52.54 	 Not on Contract Fee Schedule 	$52.54 	$58.08 	$92.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99367	MD			User Defined	30	$94.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$58.08 	$52.54 	 Not on Contract Fee Schedule 	$52.54 	$58.08 	$92.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	APRN			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	LAC			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	LCMFT			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	LCP			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	LCPC			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	LCSW			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	LMFT			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	LMLP			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	LMLPT			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	LMSW			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	LP			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$32.43 	$29.18 	 Not on Contract Fee Schedule 	$29.18 	$32.43 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	LPC			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	LPT			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$32.43 	$29.18 	 Not on Contract Fee Schedule 	$29.18 	$32.43 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	LSCSW			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	MA			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	MS			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	MSN			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	MSW			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	PA			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	PHD			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	PSYD			User Defined	30	$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$84.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	ACW			User Defined	30	$41.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$40.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	BA			User Defined	30	$41.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$40.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	BS			User Defined	30	$41.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$40.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	CCM			User Defined	30	$41.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$40.00 	Outpatient
CASECONFWO	Case Conference Without Patient	99368	MHW			User Defined	30	$41.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$35.31 	$31.71 	 Not on Contract Fee Schedule 	$31.71 	$35.31 	$40.00 	Outpatient
CBSTMTG	CBST Meeting	H0032			HA	Fixed		$86.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$84.00 	Outpatient
CHILDCLIN	CHILD Clinical Review/Coordination	(blank)				Fixed		$750.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COMMSUPP	Community Psych Support	H0036			HA	User Defined	15	$36.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$35.00 	Outpatient
COMMSUPPEB	CPST - EBP Strength Based	H0036			HK	User Defined	15	$35.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$34.00 	Outpatient
COMPEVAL	Competency Evaluation	(blank)				Fixed		$338.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$331.00 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	DO			User Defined	15	$87.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	MD			User Defined	15	$87.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	APRN			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	LAC			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	LCMFT			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	LCP			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	LCPC			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	LCSW			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	LMFT			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	LMLPT			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	LMSW			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	LP			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	LPC			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	LPT			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	LSCSW			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	MA			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	MS			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	MSN			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	MSW			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	PA			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	PHD			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	PSYD			User Defined	15	$67.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	ACW			User Defined	15	$18.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	BA			User Defined	15	$18.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	BS			User Defined	15	$18.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	CCM			User Defined	15	$18.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
COURT	Court Testimony/Expert Witness	(blank)	MHW			User Defined	15	$18.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
CRISISADV	Crisis Intervention Advanced Level	H2011			HO	User Defined	15	$47.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
CRISISBSIC	Crisis Intervention Basic Level	H2011				User Defined	15	$24.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
CRISISINTM	Crisis Intervention Intermediate Level	H2011			HK	User Defined	15	$33.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	DO			Fixed		$235.00 	$225.00 	$144.84 	$95.00 	$217.49 	$145.82 	$131.94 	$143.00 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	MD			Fixed		$235.00 	$225.00 	$144.84 	$95.00 	$217.49 	$145.82 	$131.94 	$143.00 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	APRN			Fixed		$235.00 	$225.00 	$123.11 	$95.00 	$161.96 	$136.10 	$122.21 	$121.55 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	LAC			Fixed		$235.00 	$225.00 	$108.63 	$95.00 	$152.24 	$136.10 	$122.21 	$107.25 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	LCMFT			Fixed		$235.00 	$225.00 	$108.63 	$95.00 	$152.24 	$136.10 	$122.21 	$107.25 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	LCP			Fixed		$235.00 	$225.00 	$108.63 	$95.00 	$152.24 	$136.10 	$122.21 	$107.25 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	LCPC			Fixed		$235.00 	$225.00 	$108.63 	$95.00 	$152.24 	$136.10 	$122.21 	$107.25 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	LCSW			Fixed		$235.00 	$225.00 	$108.63 	$95.00 	 Not on Contract Fee Schedule 	$136.10 	$122.21 	$107.25 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	LMFT			Fixed		$235.00 	$225.00 	$108.63 	$95.00 	$152.24 	$136.10 	$122.21 	$107.25 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	LMLP			Fixed		$235.00 	$225.00 	$108.63 	$95.00 	$152.24 	$136.10 	$122.21 	$107.25 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	LMLPT			Fixed		$235.00 	$225.00 	$108.63 	$95.00 	$152.24 	$136.10 	$122.21 	$107.25 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	LMSW			Fixed		$235.00 	$225.00 	$108.63 	$95.00 	$152.24 	$136.10 	$122.21 	$107.25 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	LP			Fixed		$235.00 	$225.00 	$123.11 	$93.00 	$185.66 	$124.99 	$112.49 	$143.00 	$93.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	LPC			Fixed		$235.00 	$225.00 	$108.63 	$95.00 	$152.24 	$136.10 	$122.21 	$107.25 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	LPT			Fixed		$235.00 	$225.00 	$123.11 	$93.00 	$185.66 	$124.99 	$112.49 	$143.00 	$93.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	LSCSW			Fixed		$235.00 	$225.00 	$108.63 	$95.00 	 Not on Contract Fee Schedule 	$136.10 	$122.21 	$107.25 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	MA			Fixed		$235.00 	$225.00 	$108.63 	$95.00 	$152.24 	$136.10 	$122.21 	$107.25 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	MS			Fixed		$235.00 	$225.00 	$108.63 	$95.00 	$152.24 	$136.10 	$122.21 	$107.25 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	MSN			Fixed		$235.00 	$225.00 	$108.63 	$95.00 	$152.24 	$136.10 	$122.21 	$107.25 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	MSW			Fixed		$235.00 	$225.00 	$108.63 	$95.00 	$152.24 	$136.10 	$122.21 	$107.25 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	PA			Fixed		$235.00 	$225.00 	$123.11 	$95.00 	 Not on Contract Fee Schedule 	$136.10 	$122.21 	$121.55 	$95.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	PHD			Fixed		$235.00 	$225.00 	$123.11 	$93.00 	$185.66 	$136.10 	$122.21 	$107.25 	$93.00 	$225.00 	 N/A 	Outpatient
CRISISTHPY	Crisis Psychotherapy	90839	PSYD			Fixed		$235.00 	$225.00 	$123.11 	$93.00 	$185.66 	$136.10 	$122.21 	$107.25 	$93.00 	$225.00 	 N/A 	Outpatient
DRIVEVAL	Driving Capacity Eval	(blank)				Fixed		$188.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
EVAL	Evaluation	90791	DO			Fixed		$268.00 	$130.00 	$142.58 	$110.00 	$180.00 	$142.97 	$129.35 	$152.00 	$110.00 	$180.00 	$263.00 	Outpatient
EVAL	Evaluation	90791	MD			Fixed		$268.00 	$130.00 	$142.58 	$110.00 	$180.00 	$142.97 	$129.35 	$152.00 	$110.00 	$180.00 	$263.00 	Outpatient
EVAL	Evaluation	90791	APRN			Fixed		$214.00 	$130.00 	$121.19 	$75.00 	 Not on Contract Fee Schedule 	$133.44 	$119.82 	$130.00 	$75.00 	$133.44 	$210.00 	Outpatient
EVAL	Evaluation	90791	LCP			Fixed		$214.00 	$85.00 	$106.93 	$94.00 	$139.69 	$133.44 	$119.82 	$120.00 	$85.00 	$139.69 	$210.00 	Outpatient
EVAL	Evaluation	90791	LP			Fixed		$214.00 	$90.00 	$121.19 	$106.00 	$169.63 	$122.54 	$110.29 	$140.00 	$90.00 	$169.63 	$210.00 	Outpatient
EVAL	Evaluation	90791	LPT			Fixed		$214.00 	$90.00 	$121.19 	$106.00 	$169.63 	$122.54 	$110.29 	$140.00 	$90.00 	$169.63 	$210.00 	Outpatient
EVAL	Evaluation	90791	MSN			Fixed		$214.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$210.00 	Outpatient
EVAL	Evaluation	90791	PA			Fixed		$214.00 	$130.00 	$121.19 	$75.00 	 Not on Contract Fee Schedule 	$133.44 	$119.82 	$130.00 	$75.00 	$133.44 	$210.00 	Outpatient
EVAL	Evaluation	90791	PHD			Fixed		$214.00 	$85.00 	$121.19 	$106.00 	$169.63 	$133.44 	$119.82 	$120.00 	$85.00 	$169.63 	$210.00 	Outpatient
EVAL	Evaluation	90791	PSYD			Fixed		$214.00 	$85.00 	$121.19 	$106.00 	$169.63 	$133.44 	$119.82 	$120.00 	$85.00 	$169.63 	$210.00 	Outpatient
EVAL	Evaluation	90791	LAC			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
EVAL	Evaluation	90791	LCMFT			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$139.69 	$133.44 	$119.82 	$120.00 	$85.00 	$139.69 	$189.00 	Outpatient
EVAL	Evaluation	90791	LCPC			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
EVAL	Evaluation	90791	LCSW			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$139.69 	$133.44 	$119.82 	$120.00 	$85.00 	$139.69 	$189.00 	Outpatient
EVAL	Evaluation	90791	LMFT			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$139.69 	$133.44 	$119.82 	$120.00 	$85.00 	$139.69 	$189.00 	Outpatient
EVAL	Evaluation	90791	LMLP			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
EVAL	Evaluation	90791	LMLPT			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
EVAL	Evaluation	90791	LMSW			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
EVAL	Evaluation	90791	LPC			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
EVAL	Evaluation	90791	LSCSW			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$139.69 	$133.44 	$119.82 	$120.00 	$85.00 	$139.69 	$189.00 	Outpatient
EVAL	Evaluation	90791	MA			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
EVAL	Evaluation	90791	MS			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
EVAL	Evaluation	90791	MSW			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
EVAL	Evaluation	90791	ACW			Fixed		$143.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$140.00 	Outpatient
EVAL	Evaluation	90791	BA			Fixed		$143.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$140.00 	Outpatient
EVAL	Evaluation	90791	BS			Fixed		$143.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$140.00 	Outpatient
EVAL	Evaluation	90791	CCM			Fixed		$143.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$140.00 	Outpatient
EVAL	Evaluation	90791	MHW			Fixed		$143.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$140.00 	Outpatient
EVALDUI	Evaluation - DUI/Court Ordered	(blank)				Fixed		$161.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$158.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	DO			Fixed		$188.00 	$110.00 	$116.25 	$95.00 	$149.23 	$117.03 	$105.89 	$104.44 	$95.00 	$149.23 	$184.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	MD			Fixed		$188.00 	$110.00 	$116.25 	$95.00 	$149.23 	$117.03 	$105.89 	$104.44 	$95.00 	$149.23 	$184.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	APRN			Fixed		$171.00 	$110.00 	$98.81 	$60.00 	$111.13 	$109.23 	$98.08 	$88.77 	$60.00 	$111.13 	$168.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	LCP			Fixed		$171.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$168.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	LP			Fixed		$171.00 	$85.00 	$98.81 	$69.00 	$126.85 	$100.31 	$90.28 	$104.44 	$69.00 	$126.85 	$168.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	LPT			Fixed		$171.00 	$85.00 	$98.81 	$69.00 	$126.85 	$100.31 	$90.28 	$104.44 	$69.00 	$126.85 	$168.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	MSN			Fixed		$171.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$168.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	PA			Fixed		$171.00 	$110.00 	$98.81 	$60.00 	 Not on Contract Fee Schedule 	$109.23 	$98.08 	$88.77 	$60.00 	$110.00 	$168.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	PHD			Fixed		$171.00 	$75.00 	$98.81 	$69.00 	$126.85 	$109.23 	$98.08 	$78.33 	$69.00 	$126.85 	$168.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	PSYD			Fixed		$171.00 	$75.00 	$98.81 	$69.00 	$126.85 	$109.23 	$98.08 	$78.33 	$69.00 	$126.85 	$168.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	LAC			Fixed		$161.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$158.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	LCMFT			Fixed		$161.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$158.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	LCPC			Fixed		$161.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$158.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	LCSW			Fixed		$161.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$158.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	LMFT			Fixed		$161.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$158.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	LMLP			Fixed		$161.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$158.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	LMLPT			Fixed		$161.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$158.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	LMSW			Fixed		$161.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$158.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	LPC			Fixed		$161.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$158.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	LSCSW			Fixed		$161.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$158.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	MA			Fixed		$161.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$158.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	MS			Fixed		$161.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$158.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	MSW			Fixed		$161.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$158.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	ACW			Fixed		$117.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$115.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	BA			Fixed		$117.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$115.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	BS			Fixed		$117.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$115.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	CCM			Fixed		$117.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$115.00 	Outpatient
FAMTHERAPY	Family Therapy With Patient	90847	MHW			Fixed		$117.00 	$75.00 	$87.18 	$60.00 	$104.46 	$109.23 	$98.08 	$78.33 	$60.00 	$109.23 	$115.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	DO			Fixed		$188.00 	$110.00 	$111.73 	$95.00 	$139.02 	$112.56 	$101.84 	$100.84 	$95.00 	$139.02 	$184.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	MD			Fixed		$188.00 	$110.00 	$111.73 	$95.00 	$139.02 	$112.56 	$101.84 	$100.84 	$95.00 	$139.02 	$184.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	APRN			Fixed		$171.00 	$110.00 	$94.97 	$60.00 	$103.52 	$105.06 	$94.34 	$85.71 	$60.00 	$110.00 	$168.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	LCP			Fixed		$171.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$168.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	LP			Fixed		$171.00 	$85.00 	$94.97 	$69.00 	$118.17 	$96.48 	$86.83 	$100.84 	$69.00 	$118.17 	$168.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	LPT			Fixed		$171.00 	$85.00 	$94.97 	$69.00 	$118.17 	$96.48 	$86.83 	$100.84 	$69.00 	$118.17 	$168.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	MSN			Fixed		$171.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$168.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	PA			Fixed		$171.00 	$110.00 	$94.97 	$60.00 	 Not on Contract Fee Schedule 	$105.06 	$94.34 	$85.71 	$60.00 	$110.00 	$168.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	PHD			Fixed		$171.00 	$75.00 	$94.97 	$69.00 	$118.17 	$105.06 	$94.34 	$75.63 	$69.00 	$118.17 	$168.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	PSYD			Fixed		$171.00 	$75.00 	$94.97 	$69.00 	$118.17 	$105.06 	$94.34 	$75.63 	$69.00 	$118.17 	$168.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	LAC			Fixed		$161.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$158.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	LCMFT			Fixed		$161.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$158.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	LCPC			Fixed		$161.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$158.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	LCSW			Fixed		$161.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$158.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	LMFT			Fixed		$161.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$158.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	LMLP			Fixed		$161.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$158.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	LMLPT			Fixed		$161.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$158.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	LMSW			Fixed		$161.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$158.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	LPC			Fixed		$161.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$158.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	LSCSW			Fixed		$161.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$158.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	MA			Fixed		$161.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$158.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	MS			Fixed		$161.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$158.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	MSW			Fixed		$161.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$158.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	ACW			Fixed		$112.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$110.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	BA			Fixed		$112.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$110.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	BS			Fixed		$112.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$110.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	CCM			Fixed		$112.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$110.00 	Outpatient
FAMTHWOPT	Family Therapy Without Patient	90846	MHW			Fixed		$112.00 	$75.00 	$83.80 	$60.00 	$97.31 	$105.06 	$94.34 	$75.63 	$60.00 	$105.06 	$110.00 	Outpatient
FORMS	Prepare Complete Forms	(blank)				User Defined	15	$13.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
GPRA	GPRA Assessment	99202				Fixed		$87.00 	$61.00 	$79.75 	$40.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$82.31 	$40.00 	$82.31 	$85.00 	Outpatient
GROUPSUD	Group Therapy SUD	H0005				User Defined	15	$14.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$14.00 	Outpatient
GROUPTHRPY	Group Therapy	90853				Fixed		$59.00 	$45.00 	$40.00 	$40.00 	$42.43 	$27.96 	$25.30 	$45.00 	$25.30 	$45.00 	$58.00 	Outpatient
INDPTLVNG	Independent Living/Skill Building	T2038				User Defined	60	$48.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$47.00 	Outpatient
INDTHERAD2	Individual Therapy - Each Add 30 Min	99355				User Defined	30	$129.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$101.15 	$91.51 	 Not on Contract Fee Schedule 	$91.51 	$101.15 	$126.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	APRN			User Defined	60	$214.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$135.21 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$135.21 	$210.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	DO			User Defined	60	$214.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$178.25 	$132.57 	$119.95 	 Not on Contract Fee Schedule 	$119.95 	$178.25 	$210.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	LCP			User Defined	60	$214.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$127.10 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$127.10 	$210.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	LP			User Defined	60	$214.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$155.00 	$113.63 	$102.27 	 Not on Contract Fee Schedule 	$102.27 	$155.00 	$210.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	LPT			User Defined	60	$214.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$155.00 	$113.63 	$102.27 	 Not on Contract Fee Schedule 	$102.27 	$155.00 	$210.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	LSCSW			User Defined	60	$214.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$123.73 	$210.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	MD			User Defined	60	$214.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$178.25 	$132.57 	$119.95 	 Not on Contract Fee Schedule 	$119.95 	$178.25 	$210.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	MSN			User Defined	60	$214.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$123.73 	$210.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	PA			User Defined	60	$214.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$123.73 	$210.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	PHD			User Defined	60	$214.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$155.00 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$155.00 	$210.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	PSYD			User Defined	60	$214.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$155.00 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$155.00 	$210.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	LAC			User Defined	60	$193.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$123.73 	$189.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	LCMFT			User Defined	60	$193.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$123.73 	$189.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	LCPC			User Defined	60	$193.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$123.73 	$189.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	LCSW			User Defined	60	$193.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$123.73 	$189.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	LMFT			User Defined	60	$193.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$123.73 	$189.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	LMLP			User Defined	60	$193.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$123.73 	$189.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	LMLPT			User Defined	60	$193.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$123.73 	$189.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	LMSW			User Defined	60	$193.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$123.73 	$189.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	LPC			User Defined	60	$193.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$123.73 	$189.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	MA			User Defined	60	$193.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$123.73 	$189.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	MS			User Defined	60	$193.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$123.73 	$189.00 	Outpatient
INDTHERADD	Individual Therapy First Additional Hour	99354	MSW			User Defined	60	$193.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$123.73 	$111.11 	 Not on Contract Fee Schedule 	$111.11 	$123.73 	$189.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	APRN	53-1440		User Defined	53+	$214.00 	$100.00 	$118.00 	$75.00 	 Not on Contract Fee Schedule 	$130.55 	$117.22 	$100.00 	$75.00 	$130.55 	$210.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	DO	53-1440		User Defined	53+	$214.00 	$100.00 	$138.82 	$110.00 	$180.00 	$139.87 	$126.55 	$125.00 	$100.00 	$180.00 	$210.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	LCP	53-1440		User Defined	53+	$214.00 	$70.00 	$104.11 	$91.00 	$146.39 	$130.55 	$117.22 	$95.00 	$70.00 	$146.39 	$210.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	LP	53-1440		User Defined	53+	$214.00 	$80.00 	$118.00 	$103.00 	$177.76 	$119.89 	$107.90 	$100.00 	$80.00 	$177.76 	$210.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	LPT	53-1440		User Defined	53+	$214.00 	$80.00 	$118.00 	$103.00 	$177.76 	$119.89 	$107.90 	$100.00 	$80.00 	$177.76 	$210.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	LSCSW	53-1440		User Defined	53+	$214.00 	$70.00 	$104.11 	$91.00 	$118.22 	$130.55 	$117.22 	$95.00 	$70.00 	$130.55 	$210.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	MD	53-1440		User Defined	53+	$214.00 	$100.00 	$138.82 	$110.00 	$180.00 	$139.87 	$126.55 	$125.00 	$100.00 	$180.00 	$210.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	MSN	53-1440		User Defined	53+	$214.00 	$70.00 	$104.11 	$91.00 	$146.39 	$130.55 	$117.22 	$95.00 	$70.00 	$146.39 	$210.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	PA	53-1440		User Defined	53+	$214.00 	$100.00 	$118.00 	$75.00 	 Not on Contract Fee Schedule 	$130.55 	$117.22 	$100.00 	$75.00 	$130.55 	$210.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	PHD	53-1440		User Defined	53+	$214.00 	$70.00 	$118.00 	$103.00 	$177.76 	$130.55 	$117.22 	$95.00 	$70.00 	$177.76 	$210.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	PSYD	53-1440		User Defined	53+	$214.00 	$70.00 	$118.00 	$103.00 	$177.76 	$130.55 	$117.22 	$95.00 	$70.00 	$177.76 	$210.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	LAC	53-1440		User Defined	53+	$193.00 	$70.00 	$104.11 	$91.00 	$146.39 	$130.55 	$117.22 	$95.00 	$70.00 	$146.39 	$189.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	LCMFT	53-1440		User Defined	53+	$193.00 	$70.00 	$104.11 	$91.00 	$146.39 	$130.55 	$117.22 	$95.00 	$70.00 	$146.39 	$189.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	LCPC	53-1440		User Defined	53+	$193.00 	$70.00 	$104.11 	$91.00 	$146.39 	$130.55 	$117.22 	$95.00 	$70.00 	$146.39 	$189.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	LCSW	53-1440		User Defined	53+	$193.00 	$70.00 	$104.11 	$91.00 	$118.22 	$130.55 	$117.22 	$95.00 	$70.00 	$130.55 	$189.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	LMFT	53-1440		User Defined	53+	$193.00 	$70.00 	$104.11 	$91.00 	$146.39 	$130.55 	$117.22 	$95.00 	$70.00 	$146.39 	$189.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	LMLP	53-1440		User Defined	53+	$193.00 	$70.00 	$104.11 	$91.00 	$146.39 	$130.55 	$117.22 	$95.00 	$70.00 	$146.39 	$189.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	LMLPT	53-1440		User Defined	53+	$193.00 	$70.00 	$104.11 	$91.00 	$146.39 	$130.55 	$117.22 	$95.00 	$70.00 	$146.39 	$189.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	LMSW	53-1440		User Defined	53+	$193.00 	$70.00 	$104.11 	$91.00 	$146.39 	$130.55 	$117.22 	$95.00 	$70.00 	$146.39 	$189.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	LPC	53-1440		User Defined	53+	$193.00 	$70.00 	$104.11 	$91.00 	$146.39 	$130.55 	$117.22 	$95.00 	$70.00 	$146.39 	$189.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	MA	53-1440		User Defined	53+	$193.00 	$70.00 	$104.11 	$91.00 	$146.39 	$130.55 	$117.22 	$95.00 	$70.00 	$146.39 	$189.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	MS	53-1440		User Defined	53+	$193.00 	$70.00 	$104.11 	$91.00 	$146.39 	$130.55 	$117.22 	$95.00 	$70.00 	$146.39 	$189.00 	Outpatient
INDTHERAPY	Individual Therapy	90837	MSW	53-1440		User Defined	53+	$193.00 	$70.00 	$104.11 	$91.00 	$146.39 	$130.55 	$117.22 	$95.00 	$70.00 	$146.39 	$189.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	LAC	38-52		User Defined	38-52	$145.00 	$75.00 	$69.41 	$64.00 	$94.70 	$86.96 	$78.08 	$80.00 	$64.00 	$94.70 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	LCMFT	38-52		User Defined	38-52	$145.00 	$75.00 	$69.41 	$64.00 	$94.70 	$86.96 	$78.08 	$80.00 	$64.00 	$94.70 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	LCP	38-52		User Defined	38-52	$145.00 	$75.00 	$69.41 	$64.00 	$94.70 	$86.96 	$78.08 	$80.00 	$64.00 	$94.70 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	LCPC	38-52		User Defined	38-52	$145.00 	$75.00 	$69.41 	$64.00 	$94.70 	$86.96 	$78.08 	$80.00 	$64.00 	$94.70 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	LCSW	38-52		User Defined	38-52	$145.00 	$75.00 	$69.41 	$64.00 	$74.90 	$86.96 	$78.08 	$80.00 	$64.00 	$86.96 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	LMFT	38-52		User Defined	38-52	$145.00 	$75.00 	$69.41 	$64.00 	$94.70 	$86.96 	$78.08 	$80.00 	$64.00 	$94.70 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	LMLP	38-52		User Defined	38-52	$145.00 	$75.00 	$69.41 	$64.00 	$94.70 	$86.96 	$78.08 	$80.00 	$64.00 	$94.70 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	LMLPT	38-52		User Defined	38-52	$145.00 	$75.00 	$69.41 	$64.00 	$94.70 	$86.96 	$78.08 	$80.00 	$64.00 	$94.70 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	LMSW	38-52		User Defined	38-52	$145.00 	$75.00 	$69.41 	$64.00 	$94.70 	$86.96 	$78.08 	$80.00 	$64.00 	$94.70 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	LP	38-52		User Defined	38-52	$145.00 	$85.00 	$78.66 	$73.00 	$115.00 	$79.86 	$71.87 	$85.00 	$71.87 	$115.00 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	LPC	38-52		User Defined	38-52	$145.00 	$75.00 	$69.41 	$64.00 	$94.70 	$86.96 	$78.08 	$80.00 	$64.00 	$94.70 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	LPT	38-52		User Defined	38-52	$145.00 	$85.00 	$78.66 	$73.00 	$115.00 	$79.86 	$71.87 	$85.00 	$71.87 	$115.00 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	LSCSW	38-52		User Defined	38-52	$145.00 	$75.00 	$69.41 	$64.00 	$74.90 	$86.96 	$78.08 	$80.00 	$64.00 	$86.96 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	MA	38-52		User Defined	38-52	$145.00 	$75.00 	$69.41 	$64.00 	$94.70 	$86.96 	$78.08 	$80.00 	$64.00 	$94.70 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	MS	38-52		User Defined	38-52	$145.00 	$75.00 	$69.41 	$64.00 	$94.70 	$86.96 	$78.08 	$80.00 	$64.00 	$94.70 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	MSW	38-52		User Defined	38-52	$145.00 	$75.00 	$69.41 	$64.00 	$94.70 	$86.96 	$78.08 	$80.00 	$64.00 	$94.70 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	PHD	38-52		User Defined	38-52	$145.00 	$75.00 	$78.66 	$73.00 	$115.00 	$86.96 	$78.08 	$80.00 	$73.00 	$115.00 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	PSYD	38-52		User Defined	38-52	$145.00 	$75.00 	$78.66 	$73.00 	$115.00 	$86.96 	$78.08 	$80.00 	$73.00 	$115.00 	$142.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	APRN	38-52		User Defined	38-52	$141.00 	$110.00 	$78.66 	$60.00 	 Not on Contract Fee Schedule 	$86.96 	$78.08 	$85.00 	$60.00 	$110.00 	$138.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	DO	38-52		User Defined	38-52	$141.00 	$110.00 	$95.00 	$95.00 	$135.00 	$93.17 	$84.29 	$110.00 	$84.29 	$135.00 	$138.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	MD	38-52		User Defined	38-52	$141.00 	$110.00 	$95.00 	$95.00 	$135.00 	$93.17 	$84.29 	$110.00 	$84.29 	$135.00 	$138.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	MSN	38-52		User Defined	38-52	$141.00 	$75.00 	$69.41 	$64.00 	$94.70 	$86.96 	$78.08 	$80.00 	$64.00 	$94.70 	$138.00 	Outpatient
INDTHERAPY	Individual Therapy	90834	PA	38-52		User Defined	38-52	$141.00 	$110.00 	$78.66 	$60.00 	 Not on Contract Fee Schedule 	$86.96 	$78.08 	$85.00 	$60.00 	$110.00 	$138.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	LAC	16-37		User Defined	16-37	$97.00 	$45.00 	$51.92 	$35.00 	$68.01 	$65.33 	$58.66 	$45.00 	$35.00 	$68.01 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	LCMFT	16-37		User Defined	16-37	$97.00 	$45.00 	$51.92 	$35.00 	$68.01 	$65.33 	$58.66 	$45.00 	$35.00 	$68.01 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	LCP	16-37		User Defined	16-37	$97.00 	$45.00 	$51.92 	$35.00 	$68.01 	$65.33 	$58.66 	$45.00 	$35.00 	$68.01 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	LCPC	16-37		User Defined	16-37	$97.00 	$45.00 	$51.92 	$35.00 	$68.01 	$65.33 	$58.66 	$45.00 	$35.00 	$68.01 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	LCSW	16-37		User Defined	16-37	$97.00 	$45.00 	$51.92 	$35.00 	$51.03 	$65.33 	$58.66 	$45.00 	$35.00 	$65.33 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	LMFT	16-37		User Defined	16-37	$97.00 	$45.00 	$51.92 	$35.00 	$68.01 	$65.33 	$58.66 	$45.00 	$35.00 	$68.01 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	LMLP	16-37		User Defined	16-37	$97.00 	$45.00 	$51.92 	$35.00 	$68.01 	$65.33 	$58.66 	$45.00 	$35.00 	$68.01 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	LMLPT	16-37		User Defined	16-37	$97.00 	$45.00 	$51.92 	$35.00 	$68.01 	$65.33 	$58.66 	$45.00 	$35.00 	$68.01 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	LMSW	16-37		User Defined	16-37	$97.00 	$45.00 	$51.92 	$35.00 	$68.01 	$65.33 	$58.66 	$45.00 	$35.00 	$68.01 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	LP	16-37		User Defined	16-37	$97.00 	$50.00 	$58.84 	$39.00 	$82.58 	$59.99 	$53.99 	$55.00 	$39.00 	$82.58 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	LPC	16-37		User Defined	16-37	$97.00 	$45.00 	$51.92 	$35.00 	$68.01 	$65.33 	$58.66 	$45.00 	$35.00 	$68.01 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	LPT	16-37		User Defined	16-37	$97.00 	$50.00 	$58.84 	$39.00 	$82.58 	$59.99 	$53.99 	$55.00 	$39.00 	$82.58 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	LSCSW	16-37		User Defined	16-37	$97.00 	$45.00 	$51.92 	$35.00 	$51.03 	$65.33 	$58.66 	$45.00 	$35.00 	$65.33 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	MA	16-37		User Defined	16-37	$97.00 	$45.00 	$51.92 	$35.00 	$68.01 	$65.33 	$58.66 	$45.00 	$35.00 	$68.01 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	MS	16-37		User Defined	16-37	$97.00 	$45.00 	$51.92 	$35.00 	$68.01 	$65.33 	$58.66 	$45.00 	$35.00 	$68.01 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	MSW	16-37		User Defined	16-37	$97.00 	$45.00 	$51.92 	$35.00 	$68.01 	$65.33 	$58.66 	$45.00 	$35.00 	$68.01 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	PHD	16-37		User Defined	16-37	$97.00 	$45.00 	$58.84 	$39.00 	$82.58 	$65.33 	$58.66 	$45.00 	$39.00 	$82.58 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	PSYD	16-37		User Defined	16-37	$97.00 	$45.00 	$58.84 	$39.00 	$82.58 	$65.33 	$58.66 	$45.00 	$39.00 	$82.58 	$95.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	APRN	16-37		User Defined	16-37	$94.00 	$60.00 	$58.84 	$35.00 	 Not on Contract Fee Schedule 	$65.33 	$58.66 	$55.00 	$35.00 	$65.33 	$92.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	DO	16-37		User Defined	16-37	$94.00 	$60.00 	$69.22 	$60.00 	$90.00 	$69.99 	$63.33 	$65.00 	$60.00 	$90.00 	$92.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	MD	16-37		User Defined	16-37	$94.00 	$60.00 	$69.22 	$60.00 	$90.00 	$69.99 	$63.33 	$65.00 	$60.00 	$90.00 	$92.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	MSN	16-37		User Defined	16-37	$94.00 	$45.00 	$51.92 	$35.00 	$68.01 	$65.33 	$58.66 	$45.00 	$35.00 	$68.01 	$92.00 	Outpatient
INDTHERAPY	Individual Therapy	90832	PA	16-37		User Defined	16-37	$94.00 	$60.00 	$58.84 	$35.00 	 Not on Contract Fee Schedule 	$65.33 	$58.66 	$55.00 	$35.00 	$65.33 	$92.00 	Outpatient
INQUIRY	Inquiry	(blank)				Fixed		$64.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
INTERACTCO	Interactive Complexity	90785				Fixed		$53.00 	$4.30 	$15.42 	 Not on Contract Fee Schedule 	$19.81 	$15.48 	$14.00 	$15.06 	$4.30 	$19.81 	$52.00 	Outpatient
IOPGROUP	IOP Group Therapy	H0015		180+		User Defined	180+	$176.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$172.00 	Outpatient
IPHOSPITAL	Inpatient Hospital	124				Fixed		$944.00 	$603.00 	$702.00 	$702.00 	$872.66 	$366.43 	$331.53 	$750.00 	$331.53 	$872.66 	$925.00 	Inpatient
IPLAB	Inpatient Lab	300				Fixed		 Varies 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 Varies 	Inpatient
IPMEDCRD1	Medical Care IP 1st Day-Straight Forward	90792				Fixed		$225.00 	$130.00 	$159.51 	$138.00 	$201.67 	$159.80 	$144.58 	$152.00 	$130.00 	$201.67 	$221.00 	Inpatient
IPMEDCRD2	Medical Care IP 1st Day-Moderate Complex	90792				Fixed		$338.00 	$130.00 	$159.51 	$138.00 	$201.67 	$159.80 	$144.58 	$152.00 	$130.00 	$201.67 	$331.00 	Inpatient
IPMEDCRD3	Medical Care IP 1st Day-High Complex	99223				Fixed		$536.00 	$110.00 	$215.94 	$105.00 	$272.55 	$206.36 	$186.70 	$235.35 	$105.00 	$272.55 	$525.00 	Inpatient
IPMEDCRDC1	Medical Care IP Dschg 1	99238	DO			Fixed		$123.00 	$45.00 	$77.87 	$95.00 	$105.00 	$74.32 	$67.24 	$83.70 	$45.00 	$105.00 	$121.00 	Inpatient
IPMEDCRDC1	Medical Care IP Dschg 1	99238	MD			Fixed		$123.00 	$45.00 	$77.87 	$95.00 	$105.00 	$74.32 	$67.24 	$83.70 	$45.00 	$105.00 	$121.00 	Inpatient
IPMEDCRDC1	Medical Care IP Dschg 1	99238	APRN			Fixed		$112.00 	$45.00 	$66.19 	 Not on Contract Fee Schedule 	$91.37 	$69.36 	$62.29 	$80.00 	$45.00 	$91.37 	$110.00 	Inpatient
IPMEDCRDC1	Medical Care IP Dschg 1	99238	MSN			Fixed		$112.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$69.36 	$62.29 	 Not on Contract Fee Schedule 	$62.29 	$69.36 	$110.00 	Inpatient
IPMEDCRDC1	Medical Care IP Dschg 1	99238	PA			Fixed		$112.00 	$45.00 	$66.19 	 Not on Contract Fee Schedule 	$91.37 	$69.36 	$62.29 	$80.00 	$45.00 	$91.37 	$110.00 	Inpatient
IPMEDCRDC2	Medical Care IP Dschg 2	99239				Fixed		$225.00 	$83.00 	$114.74 	$95.00 	$154.13 	$109.17 	$98.77 	$122.59 	$83.00 	$154.13 	$221.00 	Inpatient
IPMEDCRSD1	Medical Care IP Sub Day-Straight Forward	99231				Fixed		$86.00 	$27.00 	$41.76 	$43.00 	$60.00 	$40.15 	$36.33 	$80.00 	$27.00 	$80.00 	$84.00 	Inpatient
IPMEDCRSD2	Medical Care IP Sub Day-Moderate Complex	99232				Fixed		$123.00 	$45.00 	$77.50 	$56.00 	$100.27 	$74.24 	$67.17 	$85.13 	$45.00 	$100.27 	$121.00 	Inpatient
IPMEDCRSD3	Medical Care Ip Sub Day-High Complex	99233				Fixed		$225.00 	$90.00 	$110.98 	$72.00 	$141.16 	$106.18 	$96.06 	$122.25 	$72.00 	$141.16 	$221.00 	Inpatient
MEDEVAL	Med Eval	90792	DO			Fixed		$268.00 	$130.00 	$159.51 	$138.00 	$201.67 	$159.80 	$144.58 	$152.00 	$130.00 	$201.67 	$263.00 	Outpatient
MEDEVAL	Med Eval	90792	MD			Fixed		$268.00 	$130.00 	$159.51 	$138.00 	$201.67 	$159.80 	$144.58 	$152.00 	$130.00 	$201.67 	$263.00 	Outpatient
MEDEVAL	Med Eval	90792	APRN			Fixed		$214.00 	$130.00 	$135.58 	$117.00 	$163.81 	$149.15 	$133.93 	$130.00 	$117.00 	$163.81 	$210.00 	Outpatient
MEDEVAL	Med Eval	90792	MSN			Fixed		$214.00 	$85.00 	$119.63 	$75.00 	 Not on Contract Fee Schedule 	$149.15 	$133.93 	$130.00 	$75.00 	$149.15 	$210.00 	Outpatient
MEDEVAL	Med Eval	90792	PA			Fixed		$214.00 	$130.00 	$135.58 	$117.00 	$171.42 	$149.15 	$133.93 	$130.00 	$117.00 	$171.42 	$210.00 	Outpatient
MEDICATION	Medication	250				Fixed		 Varies 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 Varies 	Inpatient
MHRFRMSCR	Mental Health Reform Screen	90791	DO			Fixed		$268.00 	$130.00 	$142.58 	$110.00 	$180.00 	$142.97 	$129.35 	$152.00 	$110.00 	$180.00 	$263.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	MD			Fixed		$268.00 	$130.00 	$142.58 	$110.00 	$180.00 	$142.97 	$129.35 	$152.00 	$110.00 	$180.00 	$263.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	APRN			Fixed		$214.00 	$130.00 	$121.19 	$75.00 	 Not on Contract Fee Schedule 	$133.44 	$119.82 	$130.00 	$75.00 	$133.44 	$210.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	LCP			Fixed		$214.00 	$85.00 	$106.93 	$94.00 	$139.69 	$133.44 	$119.82 	$120.00 	$85.00 	$139.69 	$210.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	LP			Fixed		$214.00 	$90.00 	$121.19 	$106.00 	$169.63 	$122.54 	$110.29 	$140.00 	$90.00 	$169.63 	$210.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	LPT			Fixed		$214.00 	$90.00 	$121.19 	$106.00 	$169.63 	$122.54 	$110.29 	$140.00 	$90.00 	$169.63 	$210.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	MSN			Fixed		$214.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$210.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	PA			Fixed		$214.00 	$130.00 	$121.19 	$75.00 	 Not on Contract Fee Schedule 	$133.44 	$119.82 	$130.00 	$75.00 	$133.44 	$210.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	PHD			Fixed		$214.00 	$85.00 	$121.19 	$106.00 	$169.63 	$133.44 	$119.82 	$120.00 	$85.00 	$169.63 	$210.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	PSYD			Fixed		$214.00 	$85.00 	$121.19 	$106.00 	$169.63 	$133.44 	$119.82 	$120.00 	$85.00 	$169.63 	$210.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	LAC			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	LCMFT			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$139.69 	$133.44 	$119.82 	$120.00 	$85.00 	$139.69 	$189.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	LCPC			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	LCSW			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$139.69 	$133.44 	$119.82 	$120.00 	$85.00 	$139.69 	$189.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	LMFT			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$139.69 	$133.44 	$119.82 	$120.00 	$85.00 	$139.69 	$189.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	LMLP			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	LMLPT			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	LMSW			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	LPC			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	LSCSW			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$139.69 	$133.44 	$119.82 	$120.00 	$85.00 	$139.69 	$189.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	MA			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	MS			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
MHRFRMSCR	Mental Health Reform Screen	90791	MSW			Fixed		$193.00 	$85.00 	$106.93 	$94.00 	$120.76 	$133.44 	$119.82 	$120.00 	$85.00 	$133.44 	$189.00 	Outpatient
NEUBHEXAD	Neurobehavioral Status Exam Add On	96121		31+		User Defined	31+	$214.00 	$84.00 	$87.28 	$93.98 	$126.73 	$84.84 	$76.76 	$96.96 	$76.76 	$126.73 	$210.00 	Outpatient
NEUBHEXAM	Neurobehavioral Status Exam	96116		31+		User Defined	31+	$214.00 	$98.00 	$99.69 	$107.35 	$130.05 	$98.33 	$88.97 	$109.43 	$88.97 	$130.05 	$210.00 	Outpatient
NFMHSCRN	NFMH Screen Cont Stay - No Facilitator	T2011				Fixed		$326.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$319.00 	Outpatient
NHDISCDAY	NH Discharge Day < 30 Mins	99315				Fixed		$161.00 	$90.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$105.90 	$74.67 	$67.55 	$73.75 	$67.55 	$105.90 	$158.00 	Outpatient
NHDISCDAY2	NH Discharge Day > 30 Mins	99316				Fixed		$225.00 	$90.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$143.11 	$107.68 	$97.42 	$102.23 	$90.00 	$143.11 	$221.00 	Outpatient
NHMEDCKN1	Medical Care NH New-Low Complex	99304				Fixed		$193.00 	$90.00 	$97.06 	$80.00 	$128.67 	$91.74 	$83.00 	$105.05 	$80.00 	$128.67 	$189.00 	Outpatient
NHMEDCKN2	Medical Care NH New-Moderate Complex	99305				Fixed		$278.00 	$90.00 	$138.82 	$120.00 	$176.20 	$132.64 	$120.00 	$147.73 	$90.00 	$176.20 	$272.00 	Outpatient
NHMEDCKN3	Medical Care NH New-High Complex	99306				Fixed		$354.00 	$90.00 	$177.57 	$160.00 	$223.61 	$170.21 	$154.00 	$189.21 	$90.00 	$223.61 	$347.00 	Outpatient
NHMEDCR2	Medical Care NH Sub 2	99307				Fixed		$69.00 	$50.00 	$47.40 	$45.00 	$64.46 	$44.75 	$40.49 	$50.55 	$40.49 	$64.46 	$68.00 	Outpatient
NHMEDCR3	Medical Care NH Sub 3	99308	DO			Fixed		$112.00 	$50.00 	$73.74 	$65.00 	$100.83 	$69.89 	$63.23 	$77.74 	$50.00 	$100.83 	$110.00 	Outpatient
NHMEDCR3	Medical Care NH Sub 3	99308	MD			Fixed		$112.00 	$50.00 	$73.74 	$65.00 	$100.83 	$69.89 	$63.23 	$77.74 	$50.00 	$100.83 	$110.00 	Outpatient
NHMEDCR3	Medical Care NH Sub 3	99308	APRN			Fixed		$97.00 	$50.00 	$62.67 	$65.00 	$85.71 	$65.23 	$58.57 	$66.08 	$50.00 	$85.71 	$95.00 	Outpatient
NHMEDCR3	Medical Care NH Sub 3	99308	MSN			Fixed		$97.00 	$35.00 	$55.30 	$55.00 	$70.28 	$65.23 	$58.57 	 Not on Contract Fee Schedule 	$35.00 	$70.28 	$95.00 	Outpatient
NHMEDCR3	Medical Care NH Sub 3	99308	PA			Fixed		$97.00 	$50.00 	$62.67 	$65.00 	 Not on Contract Fee Schedule 	$65.23 	$58.57 	$66.08 	$50.00 	$66.08 	$95.00 	Outpatient
NHMEDCR4	Medical Care NH Sub 4	99309	DO			Fixed		$155.00 	$50.00 	$97.44 	$85.00 	$139.64 	$92.93 	$84.08 	$102.48 	$50.00 	$139.64 	$152.00 	Outpatient
NHMEDCR4	Medical Care NH Sub 4	99309	MD			Fixed		$155.00 	$50.00 	$97.44 	$85.00 	$139.64 	$92.93 	$84.08 	$102.48 	$50.00 	$139.64 	$152.00 	Outpatient
NHMEDCR4	Medical Care NH Sub 4	99309	APRN			Fixed		$134.00 	$50.00 	$82.82 	$85.00 	$118.69 	$86.73 	$77.88 	$87.11 	$50.00 	$118.69 	$131.00 	Outpatient
NHMEDCR4	Medical Care NH Sub 4	99309	MSN			Fixed		$134.00 	$35.00 	$73.08 	$75.00 	$97.33 	$86.73 	$77.88 	 Not on Contract Fee Schedule 	$35.00 	$97.33 	$131.00 	Outpatient
NHMEDCR4	Medical Care NH Sub 4	99309	PA			Fixed		$134.00 	$50.00 	$82.82 	$85.00 	 Not on Contract Fee Schedule 	$86.73 	$77.88 	$87.11 	$50.00 	$87.11 	$131.00 	Outpatient
NHMEDCR5	Medical Care NH Sub 5	99310	DO			Fixed		$214.00 	 Not on Contract Fee Schedule 	$144.84 	$115.00 	$193.40 	$137.81 	$124.69 	$152.09 	$115.00 	$193.40 	$210.00 	Outpatient
NHMEDCR5	Medical Care NH Sub 5	99310	MD			Fixed		$214.00 	 Not on Contract Fee Schedule 	$144.84 	$115.00 	$193.40 	$137.81 	$124.69 	$152.09 	$115.00 	$193.40 	$210.00 	Outpatient
NHMEDCR5	Medical Care NH Sub 5	99310	APRN			Fixed		$183.00 	 Not on Contract Fee Schedule 	$123.11 	$115.00 	$164.39 	$128.63 	$115.50 	$129.28 	$115.00 	$164.39 	$179.00 	Outpatient
NHMEDCR5	Medical Care NH Sub 5	99310	MSN			Fixed		$183.00 	 Not on Contract Fee Schedule 	$108.63 	$105.00 	$134.80 	$128.63 	$115.50 	 Not on Contract Fee Schedule 	$105.00 	$134.80 	$179.00 	Outpatient
NHMEDCR5	Medical Care NH Sub 5	99310	PA			Fixed		$183.00 	 Not on Contract Fee Schedule 	$123.11 	$115.00 	 Not on Contract Fee Schedule 	$128.63 	$115.50 	$129.28 	$115.00 	$129.28 	$179.00 	Outpatient
OCKHAP	Health Action Plan	S0280			U1	Fixed		$214.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$210.00 	Outpatient
OPMEDCK1	OP Med Check 1	99211				Fixed		$38.00 	$19.69 	$22.95 	$35.00 	$29.52 	$22.55 	$20.41 	$23.30 	$19.69 	$35.00 	$37.00 	Outpatient
OPMEDCK2	OP Med Check 2	99212				Fixed		$81.00 	$35.84 	$46.65 	$40.00 	$56.50 	$44.95 	$40.67 	$47.61 	$35.84 	$56.50 	$79.00 	Outpatient
OPMEDCK3	OP Med Check 3	99213				Fixed		$107.00 	$49.17 	$77.50 	$64.00 	$84.92 	$74.53 	$67.43 	$80.25 	$49.17 	$84.92 	$105.00 	Outpatient
OPMEDCK4	OP Med Check 4	99214				Fixed		$161.00 	$77.33 	$114.36 	$93.00 	$79.82 	$109.42 	$99.00 	$120.38 	$77.33 	$120.38 	$158.00 	Outpatient
OPMEDCK5	OP Med Check 5	99215				Fixed		$214.00 	$113.19 	$154.24 	$88.00 	$173.62 	$146.77 	$132.79 	$162.71 	$88.00 	$173.62 	$210.00 	Outpatient
PARNTSUPGR	Parent Support/Training - Group	S5110			TJ	User Defined	15	$14.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$14.00 	Outpatient
PARNTSUPIN	Parent Support/Training - Individual	S5110				User Defined	15	$14.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$14.00 	Outpatient
PARTIAL	Partial Day Hospital -RU	S0201		0-359		User Defined	60	$82.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$80.00 	Partial Hospital
PARTIAL	Partial Day Hospital -RU	S0201		360+		User Defined	60	$82.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$80.00 	Partial Hospital
PASRRSCRN	PASRR Screen Level II	(blank)				Fixed		$369.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$362.00 	Outpatient
PEERSUPGRP	Peer Support Group	H0038			HQ	User Defined	15	$12.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$12.00 	Outpatient
PEERSUPIND	Peer Support Individual	H0038				User Defined	15	$18.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$18.00 	Outpatient
PERCNTCM	Person Centered Case Management	H0006			U5	User Defined	15	$16.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$16.00 	Outpatient
PRTF	Turning Point	T2048				Fixed		$867.00 	$445.25 	$328.00 	$328.00 	$363.30 	$273.32 	$247.29 	$525.00 	$247.29 	$525.00 	$850.00 	Residential
PSYCHREHGR	Psychosocial Rehab Group - Adult	H2017			HQ	User Defined	15	$12.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$12.00 	Outpatient
PSYCHREHIN	Psychosocial Rehab - Individual	H2017				User Defined	15	$18.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$18.00 	Outpatient
PSYREHABGP	Psychosocial Rehab Group - Child	H2017			TJ	User Defined	15	$12.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$12.00 	Outpatient
PVCLIN	Child/Adol PV Client Clinical Review/Coo	(blank)				Fixed		$697.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
REPORTPREP	Psychiatric Report Preparation	(blank)				User Defined	15	$193.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
RESPITEGRP	Respite Care - Group - SED	S5150				User Defined	15	$8.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$8.00 	Outpatient
RESPITEIND	Respite Care - Individual - SED	S5150				User Defined	15	$8.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$8.00 	Outpatient
SOTPBASIC	SOTP Basic Adult	(blank)				Fixed		"$1,326.00 "	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Outpatient
STEPSTONES	Stepping Stones Monthly Fee	(blank)				Fixed		$45.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$44.00 	Outpatient
SUDEVAL	Alcohol/Drug Evaluation	H0001				Fixed		$193.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$189.00 	Outpatient
TCM	Targeted Case Management	T1017				User Defined	15	$18.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$18.00 	Outpatient
TMFACILITY	Telemed Facility Fee	Q3014				Fixed		$30.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$27.46 	$24.84 	 Not on Contract Fee Schedule 	$24.84 	$27.46 	$29.00 	Outpatient
TMS	TMS	90868				Fixed		$455.00 	$191.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$208.22 	$143.44 	$129.78 	$136.61 	$129.78 	$208.22 	$446.00 	Outpatient
TMSINITIAL	TMS - Initial Visit	90867				Fixed		$536.00 	$271.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$319.97 	$181.48 	$164.20 	$172.84 	$164.20 	$319.97 	$525.00 	Outpatient
TMSREDT	TMS ReDetermine Motor Threshold	90869				Fixed		$509.00 	$239.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$172.41 	$145.18 	$131.36 	$553.99 	$131.36 	$553.99 	$499.00 	Outpatient
TOBACCO1	Tobacco Cessation Intermediate	99406				Fixed		$27.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$21.80 	$15.07 	$13.63 	 Not on Contract Fee Schedule 	$13.63 	$21.80 	$26.00 	Outpatient
TOBACCO2	Tobacco Cessation Intensive	99407				Fixed		$54.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$42.65 	$28.81 	$26.07 	 Not on Contract Fee Schedule 	$26.07 	$42.65 	$53.00 	Outpatient
UDSCRN	Urine Drug Screen	(blank)				Fixed		$27.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$26.00 	Outpatient
UDSCRNCT	Urine Drug Screen Confirmation Testing	(blank)				Fixed		$38.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$37.00 	Outpatient
VNSWPROG	VNS Therapy Simple	95976				Fixed		$268.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$62.39 	$41.66 	$37.70 	 Not on Contract Fee Schedule 	$37.70 	$62.39 	$263.00 	Outpatient
VNSWPROGCP	VNS Therapy Complex	95977				Fixed		$268.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$83.38 	$55.35 	$50.07 	 Not on Contract Fee Schedule 	$50.07 	$83.38 	$263.00 	Outpatient
WRAPROUND	Wraparound/Facilitation/CS	H2021				User Defined	15	$23.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$15.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	$15.00 	$15.00 	$23.00 	Outpatient
NEUROTEVA2	Neuro Test Eval - Add Hour	96133				User Defined	60	$241.00 	$102.00 	$106.46 	$114.64 	$154.46 	$103.37 	$93.53 	$118.14 	$93.53 	$154.46 	$236.00 	Outpatient
NEUROTEVAL	Neuro Test Eval - First Hour	96132		31-74		User Defined	60	$241.00 	$134.00 	$139.57 	$150.28 	$203.11 	$135.51 	$122.61 	$154.87 	$122.61 	$203.11 	$236.00 	Outpatient
PSYCHNECOM	Psych / Neuropsych Testing - Computer	96146				Fixed		$5.00 	$5.00 	$2.26 	 Not on Contract Fee Schedule 	$3.39 	$1.95 	$1.77 	$2.24 	$1.77 	$5.00 	$5.00 	Outpatient
PSYCHTEVA2	Psych Testing Eval  - Add Hour	96131				User Defined	60	$214.00 	$91.00 	$94.43 	 Not on Contract Fee Schedule 	$138.05 	$92.35 	$83.55 	$105.54 	$83.55 	$138.05 	$210.00 	Outpatient
PSYCHTEVAL	Psych Testing Eval  - First Hour	96130		31-74		User Defined	60	$214.00 	$119.00 	$124.15 	 Not on Contract Fee Schedule 	$181.04 	$121.26 	$109.72 	$138.59 	$109.72 	$181.04 	$210.00 	Outpatient
TESTADMINP	Test Admin Prof - First 30 Mins	96136		16-44		User Defined	30	$107.00 	$48.00 	$50.03 	$53.88 	$70.72 	$47.37 	$42.85 	$54.13 	$42.85 	$70.72 	$105.00 	Outpatient
TESTADMINT	Test Admin Tech - First 30 Mins	96138		16-44		User Defined	30	$75.00 	$39.00 	$40.63 	$43.75 	$64.90 	$37.12 	$33.58 	$42.42 	$33.58 	$64.90 	$74.00 	Outpatient
TESTADMIP2	Test Admin Prof - Add 30 Mins	96137				User Defined	30	$107.00 	$45.00 	$46.27 	$49.82 	$65.06 	$43.72 	$39.56 	$49.97 	$39.56 	$65.06 	$105.00 	Outpatient
TESTADMIT2	Test Admin Tech - Add 30 Mins	96139				User Defined	30	$75.00 	$39.00 	$40.63 	$43.75 	$55.45 	$37.12 	$33.58 	$42.42 	$33.58 	$55.45 	$74.00 	Outpatient
OCKCC	Care Coordination (OCKCC)	S0311			U1	Fixed		$375.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$368.00 	"One Care Kansas bundle - multiple services may be provided, one charge of $350 per mo"
OCKCCM	Comprehensive Care Management	S0280			U1	Fixed		$375.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$368.00 	"One Care Kansas bundle - multiple services may be provided, one charge of $350 per mo"
OCKCTC	Comprehensive Transitional Care	G9149			U1	Fixed		$375.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$368.00 	"One Care Kansas bundle - multiple services may be provided, one charge of $350 per mo"
OCKHP	Health Promotion	G9148			U1	Fixed		$375.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$368.00 	"One Care Kansas bundle - multiple services may be provided, one charge of $350 per mo"
OCKPFS	Patient and Family Support	G9150			U1	Fixed		$375.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$368.00 	"One Care Kansas bundle - multiple services may be provided, one charge of $350 per mo"
OCKRCSS	Referral to Community and Social Support	S0221			U1	Fixed		$375.00 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	$368.00 	"One Care Kansas bundle - multiple services may be provided, one charge of $350 per mo"
CMS SHOPPABLE SERVICE NOT PROVIDED	"New patient office or other outpatient visit, typically 30 min"	99203	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"New patient office or other outpatient visit, typically 45 min"	99204	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"New patient office or other outpatient visit, typically 60 min"	99205	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"Patient office consultation, typically 40 min"	99243	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"Patient office consultation, typically 60 min"	99244	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Initial new patient preventive medicine evaluation (18-39 years)	99385	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Initial new patient preventive medicine evaluation (40-64 years)	99386	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Basic metabolic panel	80048	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"Blood test, comprehensive group of blood chemicals"	80053	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Obstetric blood test panel	80055	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"Blood test, lipids (cholesterol and triglycerides)"	80061	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Kidney function panel test	80069	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Liver function blood test panel	80076	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Manual urinalysis test with examination using microscope	81000	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Automated urinalysis test	81002	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	PSA (prostate specific antigen)	84153	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"Blood test, thyroid stimulating hormone (TSH)"	84443	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"Complete blood cell count, with differential white blood cells, automated"	85025	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"Complete blood count, automated"	85027	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"Blood test, clotting time"	85610	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Coagulation assessment blood test	85730	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"CT scan, head or brain, without contrast"	70450	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	MRI scan of brain before and after contrast	70553	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"X-Ray, lower back, minimum four views"	72110	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	MRI scan of lower spinal canal	72148	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"CT scan, pelvis, with contrast"	72193	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	MRI scan of leg joint	73721	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	CT scan of abdomen and pelvis with contrast	74177	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Ultrasound of abdomen	76700	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus	76805	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Ultrasound pelvis through vagina	76830	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Mammography of one breast	77065	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Mammography of both breasts	77066	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"Mammography, screening, bilateral"	77067	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major comlications or comorbidities	216	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Spinal fusion except cervical without major comorbid conditions or complications (MCC)	460	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Major joint replacement or reattachment of lower extremity without major comorbid conditions or complications (MCC)	470	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC)	473	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid conditions or complications (MCC)	743	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"Removal of 1 or more breast growth, open procedure"	19120	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Shaving of shoulder bone using an endoscope	29826	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Removal of one knee cartilage using an endoscope	29881	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Removal of tonsils and adenoid glands patient younger than age 12	42820	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope"	43235	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope"	43239	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Diagnostic examination of large bowel using an endoscope	45378	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Biopsy of large bowel using an endoscope	45380	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Removal of polyps or growths of large bowel using an endoscope	45385	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Ultrasound examination of lower large bowel using an endoscope	45391	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Removal of gallbladder using an endoscope	47562	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Repair of groin hernia patient age 5 years or older	49505	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Biopsy of prostate gland	55700	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Surgical removal of prostate and surrounding lymph nodes using an endoscope	55866	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"Routine obstetric care for vaginal delivery, including pre-and post-delivery care"	59400	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"Routine obstetric care for cesarean delivery, including pre-and post-delivery care"	59510	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care	59610	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Injection of substance into spinal canal of lower back or sacrum using imaging guidance	62322	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance	64483	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Removal of recurring cataract in lens capsule using laser	66821	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Removal of cataract with insertion of lens	66984	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"Electrocardiogram, routine, with interpretation and report"	93000	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Insertion of catheter into left heart for diagnosis	93452	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	Sleep study	95810	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
CMS SHOPPABLE SERVICE NOT PROVIDED	"Physical therapy, therapeutic exercise"	97110	N/A	N/A	N/A	N/A	N/A	#N/A	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 Not on Contract Fee Schedule 	 N/A 	 N/A 	 N/A 	Not provided/billed by hospital
*Updated 1/23/2024