SUBSTANCE USE DISORDER FEE SCHEDULE (eff 1-1-15) Provider Type 50 H0001 H0004 H0005 Alcohol and/or Drug Assessment Individual Outpatient Therapy Group Outpatient Therapy Rate $142.00 $20.00 $39.00 H0015 Intensive Outpatient (IOP) $125.00 H2036 Partial Hospitalization $130.00 Per diem H0014 ADAA Certified Ambulatory Detox Program $70.00 Per diem Procedure Code Service Description Unit Per assessment Per 15 minute increment Per 60-90 minute session Per diem (min. of 2 hrs of service per session. Max. 4 days per week. Min 9 hrs of service per week for an adult. Min. 6 hrs per week for adolescent) Provider Type 32 Procedure Code H0020 H0016 H0047 J8499 J8499 Service Description Methadone Maintenance Buprenorphine Services Alcohol/Drug Services; Medical/Somatic (Medical Intervention in Ambulatory Setting) Alcohol/Other Drug Abuse Services, Not Otherwise Specified Buprenorphine Buprenorphine Rate $80.00 Unit Per Week $200.00 Initial Induction $75.00 One Week $7.43 $4.15 8mg 2mg Provider Type 20 (Physicians enrolled in the DATA 2000 Waiver) Procedure Code Service Description Rate Unit 99201 99202 99203 99204 99205 Buprenorphine Initial Intake Buprenorphine Initial Intake Buprenorphine Initial Intake Buprenorphine Initial Intake Buprenorphine Initial Intake $45.67 $78.32 $113.59 $174.10 $216.65 Per visit Per visit Per visit Per visit Per visit 99211 99212 99213 99214 99215 Buprenorphine Ongoing Buprenorphine Ongoing Buprenorphine Ongoing Buprenorphine Ongoing Buprenorphine Ongoing $21.21 $46.05 $76.72 $113.09 $151.24 Per visit Per visit Per visit Per visit Per visit Provider Type 20 (Physician) Procedure Code J2315 Service Description Vivitrol Rate $2.43 Unit per unit with a max of 380 units per dose. Minimum age of use is 18. Provider Type 55 ICF-A Procedure Code 0100 (rev code) Service Description Residential Services (child and adolescent) Rate $350.00 Unit Per diem Provider Type 10 (Lab) Procedure Code G0434 G0431 G6040 Service Description Drug screen, other than chromatographic; any number of drug classes, by clia waived test or moderate complexity test, per patient Drug screening, qualitative; multiple classes by high complexity test method, per patient encounter Alcohol; any specimen except breathe Rate $15.77 $78.86 $11.51 Unit G6042 G6043 G6031 80348 G6044 G6053 G6056 Amphetamine or methamphetamine Barbiturates, not otherwise specified Benzodiazepines Buprenorphine Cocaine or metabolite Methadone Opiate(s), drug and metabolites, each procedure $15.88 $12.19 $12.84 $17.38 $16.12 $17.38 $20.70
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