TAX ID 71-1045290,,NPI  1962435792,Effective 4.1.2023,,,
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SERVICE,DESCRIPTION,AMOUNT,ADDITIONAL INFO,,Hierachy of Reimbursement,Applied Rate
Inpatient,DRG Base Rate,"$13,024.00",DRG,,1. Transfer from ER to Inpatient occurs: ,Inpatient rates will apply.
Inpatient,"One Day Short Stay:
DRG 001-999 AND Days 00000001","$4,050.00",Per Diem,,2. Transfer from Observation to Inpatient,Inpatient rates will apply.
Inpatient,"Observation (Rev Codes 762, 760)","$4,120.00",Case Rate,,3. Transfer from Surgery to Inpatient,Inpatient rates will apply.
Inpatient,"Transfer:
Discharge Status code 02, 05, 43, 66, 73","$4,050.00",Per Diem,,4. Outpatient surgery with Observation,Surgery Rates will apply.
Inpatient,"PSYCHIATRIC INPATIENT CARE:
Revenue Code 110-179, 190-219 AND DRG 876, 880-887","$1,250.00",Per Diem,,5. Transfer to Observation,Observation rate will apply
Inpatient,"INPATIENT ALCOHOL/DRUG:
Revenue Code 110-179, 190-219 AND DRG 894-897","$1,250.00",Per Diem,,6. ER services with Surgery,Surgery Rates will apply.
Inpatient,"Acute Rehab:
Revenue Code 110-179, 190-219 AND DRG 945-946","$1,250.00",Per Diem,,7. Medstop transfer to Emergency room,ER rates will apply
Inpatient,"Maternity (vaginal and C-Sections)
DRG 796-798, 805-807, 768, 783-788","$6,850.00",Case Rate,,"8. Any Laboratory or Radilogy codes billed, but not included in the schedules",Reimbursed at 50% of billed charges
Inpatient,Pass Through (Inpatient),,,,"9. MRI, CT, and Ultrasounds: 
Per Scan, Per Day","Reimbursed at 100% for 1st, 50% for each Scan after."
Inpatient,"High cost Drug:
Pays after threshold (not line item)",0.00,Included in DRG,,10. Pre-op testing is to be included in the Outpatient Surgery claim,Surgery Rates will apply.
Inpatient,Implants,0.00,Included in DRG,,,
Inpatient,Threshold,0.00,Included in DRG,,,
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Outpatient and Hospital -Owned Services (both on and off campus),,,,,,
Outpatient ,ER Case Rates ,,,,,
Outpatient ,Level 1 -5  (99281-99285),"$1,042.00",CASE RATE,,,
Outpatient ,"Critical Care :
CPT 99291 and 99292 pr 99299","$4,050.00",CASE RATE,,,
Outpatient ,,,,,,
Outpatient ,MedStop Case Rates,,,,,
Outpatient ,CPT 99211- 99215; Rev code 456,$200.00,Case Rate,,,
Outpatient ,,,,,,
Outpatient ,Radiology (MRI Rev Codes 610-619),$600.00,Per Scan + HCD,,,
Outpatient ,Radiology (CT Rev Codes 350-359),$450.00,Per Scan + HCD,,,
Outpatient ,"Ultrasounds: rev 402
HCPCS 76510-76514, 76536, 76604, 76641-76642, 76705-76706, 76770, 76775-76776, 76800, 76830, 76870, 76872-76873, 76881-76882, 76885-76886, 76970, 76999, 76801, 76805, 76810-76811, 76813, 76815-76817, 76856-76857, S9024, 76700, 76978, 0508T",$225.00,Per Scan + HCD,,,
Outpatient ,"Pet Scans: REV 404
HCPCS 78459, 78491-78492, 78608-78609, 78811-78816, G0219, G0235, S8085, G0252, 78429-78434","$1,950.00",Per Scan + HCD,,,
Outpatient ,"All other Radiology  (320-329, 340-342,400,401,403)",125%,CMS GA 99 Q1,,,
Outpatient ,Labs (rev codes 300-319),125%,CMS CLFS Q1 ,,,
Outpatient ,"Cardiac Cath: Rev 481
HCPCS 93451-93462, 93530-93533, 93563-93568","$3,760.00",Case rate + HCD,,,
Outpatient ,"PTCA: Rev 481
HCPCS C9606-C9607, C9600, C9602, C9604","$6,486.00",Case rate + HCD,,,
Outpatient ,Ungrouped,"$4,244",,,,
Outpatient ,ASC Category 1,"$2,308",Case rate + HCD,,,
Outpatient ,ASC Category 2,"$2,919",Case rate + HCD,,,
Outpatient ,ASC Category 3,"$3,530",Case rate + HCD,,,
Outpatient ,ASC Category 4,"$4,141",Case rate + HCD,,,
Outpatient ,ASC Category 5,"$4,761",Case rate + HCD,,,
Outpatient ,ASC Category 6,"$5,411",Case rate + HCD,,,
Outpatient ,ASC Category 7,"$6,059",Case rate + HCD,,,
Outpatient ,ASC Category 8,"$6,710",Case rate + HCD,,,
Outpatient ,ASC Category 9,"$7,359",Case rate + HCD,,,
Outpatient ,ASC Category 10,"$8,466",Case rate + HCD,,,
Outpatient ,,,,,,
Outpatient ,Pass Through (Outpatient),,,,,
Outpatient ,Threshold,$500.00,,,,
Outpatient ,"High cost Drug:
Pays after threshold (Total Billed charges; not line item)",50%,Revenue Code 636,,,
Outpatient ,Implants,0%,,,,
Outpatient ,All other Outpatient Percent  of charge,50%,Billed charges,,,