ADDENDUM J   SPECIAL EDUCATION PROGRAM MMIS CODES, UNITS, RATES April 2004       HCPCs      SERVICES                                                   Unit                                                          Rate                                                                                                                                X0201     Physical Therapy Evaluation      1 Hour (min. 31min.)                                      $ 85.00       X0202     Ind. P.T. W/Licensed PT      1/2 Hour (min. 20 min.) $ 29.00                   X0203     Ind. P.T. Program                     1/2 Hour (min. 20 min.)                $ 24.00       X0204     P.T. Program-Group               1/2 Hour (min. 20 min.) $ 19.00                                                      X0205     Occupational Therapy Evaluation      1 Hour (min. 31min.) $ 85.00       X0206     Ind.O.T. W/Licensed OT.     1/2 Hour (min. 20 min.)               $ 29.00       X0207     Ind. O.T. Program                     1/2 Hour (min. 20 min.)               $ 24.00       X0208     O.T. Program-Group               1/2 Hour (min. 20 min.)               $ 19.00                                                      X0209    Speech, Hearing, Lang. Evaluation     1 Hour (min. 31min.)                                     $ 85.00       X0210    Ind. S.H.L. w/Speech Lang. Pathologist      1/2 Hour (min. 20 min.)                                  $ 29.00       X0211    Ind. S.H.L. Program                   1/2 Hour (min. 20 min.)                                  $ 24.00       X0212    S.H.L. Program/Group             1/2 Hour (min. 20 min.)                                  $ 19.00                                                      X0521    Psychiatric Evaluation           Completed Evaluation $135.00       X0525    Psychological Evaluation         Completed Evaluation $120.00                                      X0529    Social Worker Evaluation         Completed Evaluation $ 85.00                                                      X0523    Psychiatric Counseling           1/2 Hour (min. 20 min.)                                  $ 45.00       X0527    Psychological Counseling         1/2 Hour (min. 20 min.)                                  $ 40.00       X0531    Social Worker Counseling         1/2 Hour (min. 20 min.)                                  $ 30.00       X0222    Guidance Counselor Counseling        1/2 Hour (min. 20 min.)                                  $ 29.00       X0223    Counseling Services-Group        1/2 Hour (min. 20 min.)                                 $ 20.00                                                      X0221    Nursing Services                 1/2 Hour (min. 20 min.)                                  $ 25.00       X0213    Residential Placement              1 unit equals 1 day                   M.A. Approved Cost Less Education & R. & B.       X0220    Transportation                      Individual For A Round Trip $ 10.00                                                                                                                      X0215    Non-Medical Case Mgt             1/2 hour (min. 15 min.)                                        $ 35.00       X0650    Medical Case Mgt                 1/2 hour (min. 15 min.)                                    $ 35.00       X0216    Personal Care          1/2 hour (min. 20 min.)                                        $ 10.00                                                  X0217    Day Program Services               1 unit equals 1 day   M.A. Approved Cost Less Education       X0226    Assistive Technology Device        1 unit equals 1 device Variable Rate            X0227    Assistive Technology Service        1/2 hour (min. 20 min.)                                        $ 25.00              X0229    Child Outreach Screening Completed screening     $ 60.00                X0239    Child Outreach Rescreening Completed screening          $ 25.00