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1 RUN: 02/14/17 13:08:51 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: LEGEND Listed below are some aids we hope will help you understand this fee schedule. If, after reading the information below, you need further clarification of an item, please call Molina Provider Relations at COLUMN 1. TS (Type Service): Definition: Files on which codes are loaded and from which claims are paid. The file to which a claim goes for pricing is determined by, among other things, the type of provider who is billing and by the modifier appended to the procedure code. Listed below is an explanation of the types of service found on this schedule School Boards and Early Intervention Centers COLUMNS 2, 3 and 4. CODE, DESCRIPTION, and FEE. COLUMN 5 UVS: An 'X' in this column means more than one unit of service per day may be billed.

2 RUN: 02/14/17 13:08:51 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: 1 12 H0001 HM ALCOHOL/DRUG ASSESSMT, LESS THAN BA H0001 HN ALCOHOL/DRUG ASSESSMT, BA LEVEL H0001 HO ALCOHOL/DRUG ASSESSMT, MASTERS LEVEL H0004 HM HF BH COUNSELING & THERAPY, LESS THN BA H0004 HN HF BH COUNSELING & THERAPY, BA LEVEL H0004 HO HF BH COUNSELING & THERAPY, MASTERS LVL H0005 HM ALCOHOL/DRUG SVC, LESS THAN BA 1.63 X 12 H0005 HM HR ALCOHOL/DRUG SVC, LESS THAN BA H0005 HM HS ALCOHOL/DRUG SVC, LESS THAN BA H0005 HN ALCOHOL/DRUG SVC, BA LEVEL H0005 HN HR ALCOHOL/DRUG SVC, BA LEVEL H0005 HN HS ALCOHOL/DRUG SVC, BA LEVEL H0005 HO ALCOHOL/DRUG SVC, GROUP, MASTERS LVL H0005 HO HR ALCOHOL/DRUG SVC, MASTERS LEVEL H0005 HO HS ALCOHOL/DRUG SVC, MASTERS LEVEL H0036 HN HOME/COMMUN PSYCH SUPPT, BA LEVEL H0036 HO HOME/COMMUN PSYCH SUPPT, MASTERS LVL T1001 EPSDT NURSING ASSESSMENT/EVALUATION X 12 T1002 IMPLEMENTATION OF PHYSICIANS ORDERS X 12 T1018 NURSING ASSESSMENT/EVALUATION X 12 T1502 MEDICATION ADMINISTRATION X AH INTERACTIVE COMPLEXITY -ADD-ON HO INTERACTIVE COMPLEXITY, ADD-ON.60 X AH PSYCH DIAG INTERVIEW/EXAM,LIC PSYCHO HO PSYCH DIAG INTERVIEW/EXAM, OTH LIC DIAGNOSTIC INTERVIEW INTERACT. PSYCH DIAG. INTERVIEW EXAM IND PSYCHOTHER INSIGHT ORIE 20-30MIN IND PSYCHOTHER INSIGHT ORIE 45-50MIN INDIV. PSYCHOTHERAPY INTERACT, INDIV PSYCHOTHERAPY, INTERACT, AH IND PSYCHOTHER, 30 MIN, OTH LIC PROF HF IND PSYCHOTHER, 30 MIN, OTH LIC HO IND PSYCHOTHER, 30 MIN OTH LIC AH IND PSYCHOTHER, 45 MIN, LIC PSYCHOLO HF IND. PSYCHOTHER, 45 MIN LIC PSYCHOLO HO IND. PSYCHOTHER, 45 MIN LIC PSYCHOLO AH IND PSYCHOTHER, 60 MIN, OTH LIC PROF HO IND.PSYCHOTHER, 60 MIN. OTH LIC PROF FAMILY PSYCHOTHERAPY W/P PT PRESENT AH HS FAM PSYCHOTHER, LIC PSYCHOLOGIST 12.53

3 RUN: 02/14/17 13:08:51 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: HF HS IND. PSYCHOTHER HO HS IND. PSYCHOTHER FAM PSYCHOTHERAPY W/ PATIENT PRESENT AH HR FAM PSYCHOTHER, LIC PSYCHOLOGIST HF HR FAM PSYCHO. THERAPY WITH PATIENT PRE HO HR FAM PSYCHO THERAPY W/PATIENT PRESENT GROUP PSYCHOTHERAPY AH GROUP PSYCHOTHER, LIC PSYCHOLOGIST HF GROUP PSYCHOTHERAPY 3.86 X HO GROUP PSYCHOTHERAPY INTERACTIVE GROUP PSYCHOTHERAPY HO INTERACTIVE COMPLEXITY, ADD-ON.60 X SPEECH LANGUAGE HEARING EVALUATION SPEECH LANGUAGE HEARING THERAPY, IND SPEECH LANGUAGE HEARING THER, GROUP EVALUATION OF SPEECH FLUENCY EVALUATION OF SPEECH SOUND PRODUCTIO EVALUATION OF SPEECH SOUND PRODUC BEHAVIORAL & QUALITATIVE ANALYSIS OF EPSDT - HEARING SCREENING PURE TONE AUDIOMETRY, AIR ONLY PURE AUDIOMETRY; AIR AND BONE SPEECH AUDIOMETRY; THRESHOLD ONLY SPEECH AUDIOMETRY, COMPLETE BASIC COMPREHENSIVE AUDIOMETRY TONE DECAY HEARING TEST SHORT INCREMENT SENSITIVITY INDEX STENGER TEST, PURE TONE TYMPANOMETRY ACOUSTIC REFLEX TESTING ACOUSTIC REFLEX DECAY TEST ACOUSTIC IMMITTANCE TESTING INCLUDE FILTERED SPEECH TEST STAGGERED SPONDAIC WORD TEST SENSORINEURAL ACUITY TEST SYNTHETIC SENTENCE TEST STENGER TEST, SPEECH CONDITIONING PLAY AUDIOMETRY SELECT PICTURE AUDIOMETRY ELECTROCOCHLEOGRAPHY BRAINSTEM EVOKED RESPONSE RECORDING

4 RUN: 02/14/17 13:08:51 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: AUDITORY EVOKED POTENT,LIMITED DISTORTION PRODUCT EVOKED OTOACOUSTI DISTORTION PRODUCT EVOKED OTOACOUSTI HEARING AID EXAM/SELECTION;MONAURAL HEARING AID EXAM & SELECTION BINAURA HEARING AID CHECK; MONAURAL HEARING AID CHECK; BINAURAL ELECTROACOUSTIC EVAL F HEAR AID;MONA ELECTROACOUSTIC EVAL HEAR AID;BINAUR ORAL SPEECH DEVICE EVAL PSYCHOLOGICAL TESTING PSYCHOLOGICAL TESTING WITH INTERPRET AH PSYCH TESTING, LIC PSYCHOLOGIST AH PSYCH TESTING, LIC PSYCHOLOGIST AH PSYC TESTING, LIC PSYCHOLOGIST AH NEUROPSYCH TESTING PER HR, LIC PSYCH AH NEUROPSYCH TESTING PER HOUR, LIC PSY AH NEUROPSYCH TESTING PER HOUR, LIC PSY AH ASSESS HLTH/BEHAV, INIT, L/C PSYCHOL AH ASSESS HLTH/BEHAV, SUBSEQ, LIC PSYCH AH INTERVENE HLTH/BEHAV, LIC PSYCHOLOGI AH INTERV HLTH/BEHAV, 15 MIN, LIC PSYCH AH INTERV HLTH/BEHAV, 15 MIN, LIC PSYCH AH HR GROUP PSYCHOTHERAPY 2.97 X AH INTERV HLTH/BEHAV, 15 MIN, LIC PSYCH AH HS INTERV. HLTH/BEHAV, 15 MIN. LIC PSYC 3.19 X PT EVALUATION OT EVALUATION ELECTRICAL STIMULATION,EACH 15 MIN X THERAPEUTIC PROC, 1 OR MORE, 15 MIN X NEUROMUSCULAR RE-EDUCATION,EACH 15MI X GAIT TRAINING, EACH 15 MIN X PT-MASSAGE-30 MIN X PT EVAL - LOW COMPLEXITY PT EVAL - MODERATE COMPLEXITY PT EVAL - HIGH COMPLEXITY OT EVAL-LOW COMPLEXITY OT EVAL-MODERATE COMPLEXITY OT EVAL-HIGH COMPLEXITY ORTHOTIC TRAINING,EACH 15 MIN 8.00 X THERAPEUTIC ACTIVITIES 15 MINUTES 8.00 X

5 RUN: 02/14/17 13:08:51 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: PHYSICAL PERFORMANCE TEST, 15 MIN 8.00 X ORTHOTIC MGMT AND TRAINING 8.00 X EP EPSDT-VISION SCREENING 10.00