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CLINICAL OPERATIONS MOU <br />EXHIBIT 1- MEDICAID -EQUIVALENT RATE REFERENCE <br />The controlling amount is the Washington HCA fee -for -service maximum allowable amount effective on the service <br />date for the correct code, modifier, unit, provider type, age, place of service, and facility designation. The examples <br />below verify the July 1, 2026 schedules; they are not a frozen rate card. <br />Category <br />Code <br />Modifier <br />NFS <br />FS <br />Description/note <br />Mental health <br />90791 <br />None <br />$127.46 <br />$99.23 <br />Psychiatric diagnostic <br />evaluation <br />Mental health <br />90834 <br />None <br />$83.48 <br />$66.31 <br />Psychotherapy, 45 <br />minutes <br />Mental health <br />90837 <br />None <br />$122.51 <br />$97.82 <br />Psychotherapy, 60 <br />minutes <br />SUD <br />H0001 <br />HF <br />$161.59 <br />Same <br />SUD assessment <br />Individual SUD <br />SUD <br />H0004 <br />HF <br />$31.07 <br />Same <br />therapy, per 15 <br />minutes (HCPCS <br />unit) <br />SUD <br />T1017 <br />HF <br />$14.20 <br />Same <br />Case management, <br />each 15 minutes <br />Established patient <br />Behavioral -health <br />99213 <br />None <br />$42.65 <br />$25.08 <br />E/M; behavioral - <br />practitioner E/M <br />health medication <br />management only <br />Established patient <br />Behavioral -health <br />g9214 <br />None <br />$6065 <br />$36.70 <br />E/M; behavioral - <br />practitioner E/M <br />. <br />health medication <br />management only <br />NFS = non -facility setting; FS = facility setting. HCA billing guides determine which amount applies. Enhanced, age - <br />specific, telehealth, or other HCA rules may change the payable amount. <br />KITTITAS COUNTY / VALLEY HEALTH AND COUNSELING I Page 4 <br />