| 
                        Group Therapy
                     | 
                    
                        Professional
                     | 
                    
                        Both
                     | 
                    
                        $30.00
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                CPT 90853 
                                             | 
                                         
                                    
                                    
                                    
                                        | Hospital Charge Code | 
                                        
                                            2790853
                                         | 
                                     
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $19.53 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $55.00 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Aetna Better Health CHIP/Medicaid | 
                                            
                                                $23.32
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Aetna Better Health Medicare-Medicaid Dual Eligibility | 
                                            
                                                $24.41
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Behavioral Services Network Commercial | 
                                            
                                                $26.85
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Behavioral Services Network Medicare | 
                                            
                                                $24.41
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Carelon Commercial/Medicare | 
                                            
                                                $55.00
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Carelon Commercial/Medicare | 
                                            
                                                $35.00
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Carelon Medicare | 
                                            
                                                $24.41
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Humana Commercial | 
                                            
                                                $31.78
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Humana Commercial | 
                                            
                                                $34.23
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Humana Commercial | 
                                            
                                                $29.34
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Humana Medicare | 
                                            
                                                $34.23
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Humana Medicare | 
                                            
                                                $31.78
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Humana Medicare | 
                                            
                                                $29.34
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Lucet Commercial | 
                                            
                                                $19.53
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Lucet Commercial | 
                                            
                                                $23.19
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Lucet Commercial | 
                                            
                                                $21.97
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Magellan Medicaid | 
                                            
                                                $22.21
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Molina Complete Care Medicaid/Medicare | 
                                            
                                                $24.41
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Prime Health Services Workers Comp | 
                                            
                                                $42.92
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        Gynecologic Preventive Medicine
                     | 
                    
                        Facility
                     | 
                    
                        OP
                     | 
                    
                        $0.22
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                EAPG 00878 
                                             | 
                                         
                                    
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $0.22 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $0.22 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Sunshine Health Medicaid | 
                                            
                                                $0.22
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        Headaches Other Than Migraine
                     | 
                    
                        Facility
                     | 
                    
                        OP
                     | 
                    
                        $0.37
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                EAPG 00530 
                                             | 
                                         
                                    
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $0.37 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $0.37 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Sunshine Health Medicaid | 
                                            
                                                $0.37
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        Head Trauma With Loc/Coma More Then 1 Hr
                     | 
                    
                        Facility
                     | 
                    
                        OP
                     | 
                    
                        $1.10
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                EAPG 00538 
                                             | 
                                         
                                    
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $1.10 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $1.10 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Sunshine Health Medicaid | 
                                            
                                                $1.10
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        Head Trauma With Or Without Loc/Coma Less Than 1 Hr
                     | 
                    
                        Facility
                     | 
                    
                        OP
                     | 
                    
                        $0.49
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                EAPG 00532 
                                             | 
                                         
                                    
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $0.49 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $0.49 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Sunshine Health Medicaid | 
                                            
                                                $0.49
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        Heart And/Or Lung Transplant
                     | 
                    
                        Facility
                     | 
                    
                        OP
                     | 
                    
                        $26.54
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                EAPG 03051 
                                             | 
                                         
                                    
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $26.54 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $26.54 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Sunshine Health Medicaid | 
                                            
                                                $26.54
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        Heart Failure
                     | 
                    
                        Facility
                     | 
                    
                        OP
                     | 
                    
                        $0.41
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                EAPG 00594 
                                             | 
                                         
                                    
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $0.41 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $0.41 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Sunshine Health Medicaid | 
                                            
                                                $0.41
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        Hepatic Coma And Major Acute Liver Diagnoses
                     | 
                    
                        Facility
                     | 
                    
                        OP
                     | 
                    
                        $0.33
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                EAPG 00641 
                                             | 
                                         
                                    
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $0.33 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $0.33 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Sunshine Health Medicaid | 
                                            
                                                $0.33
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        Hepatitis Without Coma
                     | 
                    
                        Facility
                     | 
                    
                        OP
                     | 
                    
                        $0.34
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                EAPG 00636 
                                             | 
                                         
                                    
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $0.34 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $0.34 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Sunshine Health Medicaid | 
                                            
                                                $0.34
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        Hernia
                     | 
                    
                        Facility
                     | 
                    
                        OP
                     | 
                    
                        $0.32
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                EAPG 00631 
                                             | 
                                         
                                    
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $0.32 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $0.32 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Sunshine Health Medicaid | 
                                            
                                                $0.32
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        Hiv Infection
                     | 
                    
                        Facility
                     | 
                    
                        OP
                     | 
                    
                        $0.48
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                EAPG 00880 
                                             | 
                                         
                                    
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $0.48 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $0.48 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Sunshine Health Medicaid | 
                                            
                                                $0.48
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        H. Pylori Infection
                     | 
                    
                        Facility
                     | 
                    
                        OP
                     | 
                    
                        $0.26
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                EAPG 00810 
                                             | 
                                         
                                    
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $0.26 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $0.26 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Sunshine Health Medicaid | 
                                            
                                                $0.26
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        Hypertension
                     | 
                    
                        Facility
                     | 
                    
                        OP
                     | 
                    
                        $0.29
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                EAPG 00599 
                                             | 
                                         
                                    
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $0.29 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $0.29 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Sunshine Health Medicaid | 
                                            
                                                $0.29
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        Inborn Errors Of Metabolism
                     | 
                    
                        Facility
                     | 
                    
                        OP
                     | 
                    
                        $0.24
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                EAPG 00691 
                                             | 
                                         
                                    
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $0.24 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $0.24 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Sunshine Health Medicaid | 
                                            
                                                $0.24
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        Incision and drainage abscess (complicated or multiple)
                     | 
                    
                        Professional
                     | 
                    
                        Both
                     | 
                    
                        $649.00
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                CPT 10061 
                                             | 
                                         
                                    
                                    
                                    
                                        | Hospital Charge Code | 
                                        
                                            610061
                                         | 
                                     
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $143.14 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $412.52 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Aetna Better Health CHIP/Medicaid | 
                                            
                                                $172.65
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Aetna Better Health Medicare-Medicaid Dual Eligibility | 
                                            
                                                $178.92
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Behavioral Services Network Commercial | 
                                            
                                                $196.81
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Behavioral Services Network Medicare | 
                                            
                                                $178.92
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Carelon Medicare | 
                                            
                                                $178.92
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Lucet Commercial | 
                                            
                                                $169.97
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Lucet Commercial | 
                                            
                                                $161.03
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Lucet Commercial | 
                                            
                                                $143.14
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Magellan Medicaid | 
                                            
                                                $164.43
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Molina Complete Care Medicaid/Medicare | 
                                            
                                                $178.92
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Prime Health Services Workers Comp | 
                                            
                                                $412.52
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        Incision and drainage abscess (cutaneous or subcutaneous)
                     | 
                    
                        Professional
                     | 
                    
                        Both
                     | 
                    
                        $374.00
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                CPT 10060 
                                             | 
                                         
                                    
                                    
                                    
                                        | Hospital Charge Code | 
                                        
                                            510060
                                         | 
                                     
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $82.48 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $241.28 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Aetna Better Health CHIP/Medicaid | 
                                            
                                                $102.94
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Aetna Better Health Medicare-Medicaid Dual Eligibility | 
                                            
                                                $103.10
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Behavioral Services Network Commercial | 
                                            
                                                $113.41
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Behavioral Services Network Medicare | 
                                            
                                                $103.10
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Carelon Medicare | 
                                            
                                                $103.10
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Lucet Commercial | 
                                            
                                                $92.79
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Lucet Commercial | 
                                            
                                                $82.48
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Lucet Commercial | 
                                            
                                                $97.94
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Magellan Medicaid | 
                                            
                                                $98.04
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Molina Complete Care Medicaid/Medicare | 
                                            
                                                $103.10
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Prime Health Services Workers Comp | 
                                            
                                                $241.28
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        Incision and drainage pilonidal cyst (simple)
                     | 
                    
                        Professional
                     | 
                    
                        Both
                     | 
                    
                        $770.00
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                CPT 10080 
                                             | 
                                         
                                    
                                    
                                    
                                        | Hospital Charge Code | 
                                        
                                            710080
                                         | 
                                     
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $82.22 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $468.54 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Aetna Better Health CHIP/Medicaid | 
                                            
                                                $197.58
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Aetna Better Health Medicare-Medicaid Dual Eligibility | 
                                            
                                                $102.77
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Behavioral Services Network Commercial | 
                                            
                                                $113.05
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Behavioral Services Network Medicare | 
                                            
                                                $102.77
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Carelon Medicare | 
                                            
                                                $102.77
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Lucet Commercial | 
                                            
                                                $92.49
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Lucet Commercial | 
                                            
                                                $97.63
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Lucet Commercial | 
                                            
                                                $82.22
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Magellan Medicaid | 
                                            
                                                $188.17
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Molina Complete Care Medicaid/Medicare | 
                                            
                                                $102.77
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Prime Health Services Workers Comp | 
                                            
                                                $468.54
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        In-Depth Assessment - Established Client
                     | 
                    
                        Professional
                     | 
                    
                        Both
                     | 
                    
                        $210.00
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                CPT H0031 TS
                                             | 
                                         
                                    
                                    
                                    
                                        | Hospital Charge Code | 
                                        
                                            72H0031
                                         | 
                                     
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $100.00 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $100.00 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Carelon Medicaid | 
                                            
                                                $100.00
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        In-Depth Assessment - Established Client
                     | 
                    
                        Professional
                     | 
                    
                        Both
                     | 
                    
                        $240.00
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                CPT H0001 TS
                                             | 
                                         
                                    
                                    
                                    
                                        | Hospital Charge Code | 
                                        
                                            62H0001
                                         | 
                                     
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $100.00 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $100.00 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Carelon Medicaid | 
                                            
                                                $100.00
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        In-Depth Assessment - Established Client
                     | 
                    
                        Professional
                     | 
                    
                        Both
                     | 
                    
                        $240.00
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                CPT H0001 GT
                                             | 
                                         
                                    
                                    
                                    
                                        | Hospital Charge Code | 
                                        
                                            61H0001
                                         | 
                                     
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $15.00 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $15.00 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Carelon Medicaid | 
                                            
                                                $15.00
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        In-Depth Assessment - Established Client
                     | 
                    
                        Professional
                     | 
                    
                        Both
                     | 
                    
                        $210.00
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                CPT H0031 GT
                                             | 
                                         
                                    
                                    
                                    
                                        | Hospital Charge Code | 
                                        
                                            71H0031
                                         | 
                                     
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $15.00 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $15.00 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Carelon Medicaid | 
                                            
                                                $15.00
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        In-Depth Assessment - New Client
                     | 
                    
                        Professional
                     | 
                    
                        Both
                     | 
                    
                        $240.00
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                CPT H0001 GT
                                             | 
                                         
                                    
                                    
                                    
                                        | Hospital Charge Code | 
                                        
                                            63H0001
                                         | 
                                     
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $15.00 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $15.00 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Carelon Medicaid | 
                                            
                                                $15.00
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        In-Depth Assessment - New Client
                     | 
                    
                        Professional
                     | 
                    
                        Both
                     | 
                    
                        $240.00
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                CPT H0031 HO
                                             | 
                                         
                                    
                                    
                                    
                                        | Hospital Charge Code | 
                                        
                                            74H0031
                                         | 
                                     
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $125.00 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $126.11 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Carelon Medicaid | 
                                            
                                                $125.00
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Molina Complete Care Marketplace | 
                                            
                                                $126.11
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        In-Depth Assessment - New Client
                     | 
                    
                        Professional
                     | 
                    
                        Both
                     | 
                    
                        $240.00
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                CPT H0001 HO
                                             | 
                                         
                                    
                                    
                                    
                                        | Hospital Charge Code | 
                                        
                                            64H0001
                                         | 
                                     
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $125.00 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $126.11 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Carelon Medicaid | 
                                            
                                                $125.00
                                             | 
                                         
                                    
                                        
                                            | Rate for Payer: Molina Complete Care Marketplace | 
                                            
                                                $126.11
                                             | 
                                         
                                    
                                
                             
                         
                     | 
                
            
                
                    | 
                        In-Depth Assessment - New Client
                     | 
                    
                        Professional
                     | 
                    
                        Both
                     | 
                    
                        $240.00
                     | 
                    
                        
                     | 
                
                
                    
                        
                            
                                
                                    
                                        
                                            | 
                                                Service Code
                                             | 
                                            
                                                CPT H0031 GT
                                             | 
                                         
                                    
                                    
                                    
                                        | Hospital Charge Code | 
                                        
                                            73H0031
                                         | 
                                     
                                    
                                    
                                    
                                        
                                            | Min. Negotiated Rate | 
                                            $15.00 | 
                                         
                                    
                                    
                                        
                                            | Max. Negotiated Rate | 
                                            $15.00 | 
                                         
                                    
                                    
                                        
                                            | Rate for Payer: Carelon Medicaid | 
                                            
                                                $15.00
                                             | 
                                         
                                    
                                
                             
                         
                     |