hospital_name last_updated_on version hospital_location hospital_address license_number|OH "To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated." "Mt. Airy Development, LLC" 5/31/2024 2.0.0 "Cincinnati, Ohio" 2446 Kipling Avenue license_78013|OH TRUE description code |1 code|1|type billing_class setting drug_unit_of_measurement drug_type_of_measurement modifiers standard_charge | gross standard_charge|discounted_cash standard_charge|min standard_charge | max standard_charge|[payer_AETNA]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_AETNA]|[plan_HMO/PPO]| negotiated_percentage standard_charge|[payer_AETNA]|[plan_HMO/PPO]|negotiated_algorithm estimated_amount|[payer_AETNA]|[plan_HMO/PPO] standard_charge|[payer_AETNA]|[plan_HMO/PPO] |methodology additional_payer_notes|[payer_AETNA]|[plan_HMO/PPO] standard_charge|[payer_AETNA BETTER HEALTH O]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_AETNA BETTER HEALTH O]|[plan_MANAGED MEDICAID]| negotiated_percentage standard_charge|[payer_AETNA BETTER HEALTH O]|[plan_MANAGED MEDICAID]|negotiated_algorithm estimated_amount|[payer_AETNA BETTER HEALTH O]|[plan_MANAGED MEDICAID] standard_charge|[payer_AETNA BETTER HEALTH O]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes|[payer_AETNA BETTER HEALTH O]|[plan_MANAGED MEDICAID] standard_charge|[payer_AMERIHEALTH CARITAS OHIO]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_AMERIHEALTH CARITAS OHIO]|[plan_MANAGED MEDICAID]| negotiated_percentage standard_charge|[payer_AMERIHEALTH CARITAS OHIO]|[plan_MANAGED MEDICAID]|negotiated_algorithm estimated_amount|[payer_AMERIHEALTH CARITAS OHIO]|[plan_MANAGED MEDICAID] standard_charge|[payer_AMERIHEALTH CARITAS OHIO]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes|[payer_AMERIHEALTH CARITAS OHIO]|[plan_MANAGED MEDICAID] standard_charge|[payer_ANTHEM BCBS OH]|[plan_BLUE CROSS]|negotiated_dollar standard_charge|[payer_ANTHEM BCBS OH]|[plan_BLUE CROSS]| negotiated_percentage standard_charge|[payer_ANTHEM BCBS OH]|[plan_BLUE CROSS]|negotiated_algorithm estimated_amount|[payer_ANTHEM BCBS OH]|[plan_BLUE CROSS] standard_charge|[payer_ANTHEM BCBS OH]|[plan_BLUE CROSS] |methodology additional_payer_notes|[payer_ANTHEM BCBS OH]|[plan_BLUE CROSS] standard_charge|[payer_ANTHEM MEDICAID]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_ANTHEM MEDICAID]|[plan_MANAGED MEDICAID]| negotiated_percentage standard_charge|[payer_ANTHEM MEDICAID]|[plan_MANAGED MEDICAID]|negotiated_algorithm estimated_amount|[payer_ANTHEM MEDICAID]|[plan_MANAGED MEDICAID] standard_charge|[payer_ANTHEM MEDICAID]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes|[payer_ANTHEM MEDICAID]|[plan_MANAGED MEDICAID] standard_charge|[payer_ANTHEM MEDICARE]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_ANTHEM MEDICARE]|[plan_MANAGED MEDICARE]| negotiated_percentage standard_charge|[payer_ANTHEM MEDICARE]|[plan_MANAGED MEDICARE]|negotiated_algorithm estimated_amount|[payer_ANTHEM MEDICARE]|[plan_MANAGED MEDICARE] standard_charge|[payer_ANTHEM MEDICARE]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes|[payer_ANTHEM MEDICARE]|[plan_MANAGED MEDICARE] standard_charge|[payer_BCBS FEDERAL]|[plan_BLUE CROSS]|negotiated_dollar standard_charge|[payer_BCBS FEDERAL]|[plan_BLUE CROSS]| negotiated_percentage standard_charge|[payer_BCBS FEDERAL]|[plan_BLUE CROSS]|negotiated_algorithm estimated_amount|[payer_BCBS FEDERAL]|[plan_BLUE CROSS] standard_charge|[payer_BCBS FEDERAL]|[plan_BLUE CROSS] |methodology additional_payer_notes|[payer_BCBS FEDERAL]|[plan_BLUE CROSS] standard_charge|[payer_BCBS OUT OF STATE]|[plan_BLUE CROSS]|negotiated_dollar standard_charge|[payer_BCBS OUT OF STATE]|[plan_BLUE CROSS]| negotiated_percentage standard_charge|[payer_BCBS OUT OF STATE]|[plan_BLUE CROSS]|negotiated_algorithm estimated_amount|[payer_BCBS OUT OF STATE]|[plan_BLUE CROSS] standard_charge|[payer_BCBS OUT OF STATE]|[plan_BLUE CROSS] |methodology additional_payer_notes|[payer_BCBS OUT OF STATE]|[plan_BLUE CROSS] standard_charge|[payer_BEACON HEALTH OPTIONS]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_BEACON HEALTH OPTIONS]|[plan_HMO/PPO]| negotiated_percentage standard_charge|[payer_BEACON HEALTH OPTIONS]|[plan_HMO/PPO]|negotiated_algorithm estimated_amount|[payer_BEACON HEALTH OPTIONS]|[plan_HMO/PPO] standard_charge|[payer_BEACON HEALTH OPTIONS]|[plan_HMO/PPO] |methodology additional_payer_notes|[payer_BEACON HEALTH OPTIONS]|[plan_HMO/PPO] standard_charge|[payer_BUCKEYE COMMUNITY HEALTH]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_BUCKEYE COMMUNITY HEALTH]|[plan_MANAGED MEDICAID]| negotiated_percentage standard_charge|[payer_BUCKEYE COMMUNITY HEALTH]|[plan_MANAGED MEDICAID]|negotiated_algorithm estimated_amount|[payer_BUCKEYE COMMUNITY HEALTH]|[plan_MANAGED MEDICAID] standard_charge|[payer_BUCKEYE COMMUNITY HEALTH]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes|[payer_BUCKEYE COMMUNITY HEALTH]|[plan_MANAGED MEDICAID] standard_charge|[payer_BUCKEYE MEDICARE]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_BUCKEYE MEDICARE]|[plan_MANAGED MEDICARE]| negotiated_percentage standard_charge|[payer_BUCKEYE MEDICARE]|[plan_MANAGED MEDICARE]|negotiated_algorithm estimated_amount|[payer_BUCKEYE MEDICARE]|[plan_MANAGED MEDICARE] standard_charge|[payer_BUCKEYE MEDICARE]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes|[payer_BUCKEYE MEDICARE]|[plan_MANAGED MEDICARE] standard_charge|[payer_CARESOURCE]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_CARESOURCE]|[plan_HMO/PPO]| negotiated_percentage standard_charge|[payer_CARESOURCE]|[plan_HMO/PPO]|negotiated_algorithm estimated_amount|[payer_CARESOURCE]|[plan_HMO/PPO] standard_charge|[payer_CARESOURCE]|[plan_HMO/PPO] |methodology additional_payer_notes|[payer_CARESOURCE]|[plan_HMO/PPO] standard_charge|[payer_CARESOURCE MCD]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_CARESOURCE MCD]|[plan_MANAGED MEDICAID]| negotiated_percentage standard_charge|[payer_CARESOURCE MCD]|[plan_MANAGED MEDICAID]|negotiated_algorithm estimated_amount|[payer_CARESOURCE MCD]|[plan_MANAGED MEDICAID] standard_charge|[payer_CARESOURCE MCD]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes|[payer_CARESOURCE MCD]|[plan_MANAGED MEDICAID] standard_charge|[payer_CIGNA]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_CIGNA]|[plan_HMO/PPO]| negotiated_percentage standard_charge|[payer_CIGNA]|[plan_HMO/PPO]|negotiated_algorithm estimated_amount|[payer_CIGNA]|[plan_HMO/PPO] standard_charge|[payer_CIGNA]|[plan_HMO/PPO] |methodology additional_payer_notes|[payer_CIGNA]|[plan_HMO/PPO] standard_charge|[payer_CIGNA/EVERNORTH]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_CIGNA/EVERNORTH]|[plan_HMO/PPO]| negotiated_percentage standard_charge|[payer_CIGNA/EVERNORTH]|[plan_HMO/PPO]|negotiated_algorithm estimated_amount|[payer_CIGNA/EVERNORTH]|[plan_HMO/PPO] standard_charge|[payer_CIGNA/EVERNORTH]|[plan_HMO/PPO] |methodology additional_payer_notes|[payer_CIGNA/EVERNORTH]|[plan_HMO/PPO] standard_charge|[payer_HUMANA]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_HUMANA]|[plan_HMO/PPO]| negotiated_percentage standard_charge|[payer_HUMANA]|[plan_HMO/PPO]|negotiated_algorithm estimated_amount|[payer_HUMANA]|[plan_HMO/PPO] standard_charge|[payer_HUMANA]|[plan_HMO/PPO] |methodology additional_payer_notes|[payer_HUMANA]|[plan_HMO/PPO] standard_charge|[payer_HUMANA MCR]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_HUMANA MCR]|[plan_MANAGED MEDICARE]| negotiated_percentage standard_charge|[payer_HUMANA MCR]|[plan_MANAGED MEDICARE]|negotiated_algorithm estimated_amount|[payer_HUMANA MCR]|[plan_MANAGED MEDICARE] standard_charge|[payer_HUMANA MCR]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes|[payer_HUMANA MCR]|[plan_MANAGED MEDICARE] standard_charge|[payer_HUMANA MEDICAID]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_HUMANA MEDICAID]|[plan_MANAGED MEDICAID]| negotiated_percentage standard_charge|[payer_HUMANA MEDICAID]|[plan_MANAGED MEDICAID]|negotiated_algorithm estimated_amount|[payer_HUMANA MEDICAID]|[plan_MANAGED MEDICAID] standard_charge|[payer_HUMANA MEDICAID]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes|[payer_HUMANA MEDICAID]|[plan_MANAGED MEDICAID] standard_charge|[payer_MAGELLAN]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_MAGELLAN]|[plan_HMO/PPO]| negotiated_percentage standard_charge|[payer_MAGELLAN]|[plan_HMO/PPO]|negotiated_algorithm estimated_amount|[payer_MAGELLAN]|[plan_HMO/PPO] standard_charge|[payer_MAGELLAN]|[plan_HMO/PPO] |methodology additional_payer_notes|[payer_MAGELLAN]|[plan_HMO/PPO] standard_charge|[payer_MEDICAID]|[plan_MEDICAID ]|negotiated_dollar standard_charge|[payer_MEDICAID]|[plan_MEDICAID ]| negotiated_percentage standard_charge|[payer_MEDICAID]|[plan_MEDICAID ]|negotiated_algorithm estimated_amount|[payer_MEDICAID]|[plan_MEDICAID ] standard_charge|[payer_MEDICAID]|[plan_MEDICAID ] |methodology additional_payer_notes|[payer_MEDICAID]|[plan_MEDICAID ] standard_charge|[payer_MEDICAL MUTUAL]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_MEDICAL MUTUAL]|[plan_HMO/PPO]| negotiated_percentage standard_charge|[payer_MEDICAL MUTUAL]|[plan_HMO/PPO]|negotiated_algorithm estimated_amount|[payer_MEDICAL MUTUAL]|[plan_HMO/PPO] standard_charge|[payer_MEDICAL MUTUAL]|[plan_HMO/PPO] |methodology additional_payer_notes|[payer_MEDICAL MUTUAL]|[plan_HMO/PPO] standard_charge|[payer_MEDICARE]|[plan_MEDICARE]|negotiated_dollar standard_charge|[payer_MEDICARE]|[plan_MEDICARE]| negotiated_percentage standard_charge|[payer_MEDICARE]|[plan_MEDICARE]|negotiated_algorithm estimated_amount|[payer_MEDICARE]|[plan_MEDICARE] standard_charge|[payer_MEDICARE]|[plan_MEDICARE] |methodology additional_payer_notes|[payer_MEDICARE]|[plan_MEDICARE] standard_charge|[payer_MERITAIN HEALTH]|[plan_COMMERCIAL]|negotiated_dollar standard_charge|[payer_MERITAIN HEALTH]|[plan_COMMERCIAL]| negotiated_percentage standard_charge|[payer_MERITAIN HEALTH]|[plan_COMMERCIAL]|negotiated_algorithm estimated_amount|[payer_MERITAIN HEALTH]|[plan_COMMERCIAL] standard_charge|[payer_MERITAIN HEALTH]|[plan_COMMERCIAL] |methodology additional_payer_notes|[payer_MERITAIN HEALTH]|[plan_COMMERCIAL] standard_charge|[payer_MISC COMMERICAL]|[plan_COMMERCIAL]|negotiated_dollar standard_charge|[payer_MISC COMMERICAL]|[plan_COMMERCIAL]| negotiated_percentage standard_charge|[payer_MISC COMMERICAL]|[plan_COMMERCIAL]|negotiated_algorithm estimated_amount|[payer_MISC COMMERICAL]|[plan_COMMERCIAL] standard_charge|[payer_MISC COMMERICAL]|[plan_COMMERCIAL] |methodology additional_payer_notes|[payer_MISC COMMERICAL]|[plan_COMMERCIAL] standard_charge|[payer_MOLINA MCD]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_MOLINA MCD]|[plan_MANAGED MEDICAID]| negotiated_percentage standard_charge|[payer_MOLINA MCD]|[plan_MANAGED MEDICAID]|negotiated_algorithm estimated_amount|[payer_MOLINA MCD]|[plan_MANAGED MEDICAID] standard_charge|[payer_MOLINA MCD]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes|[payer_MOLINA MCD]|[plan_MANAGED MEDICAID] standard_charge|[payer_MOLINA MYCARE MEDICARE]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_MOLINA MYCARE MEDICARE]|[plan_MANAGED MEDICARE]| negotiated_percentage standard_charge|[payer_MOLINA MYCARE MEDICARE]|[plan_MANAGED MEDICARE]|negotiated_algorithm estimated_amount|[payer_MOLINA MYCARE MEDICARE]|[plan_MANAGED MEDICARE] standard_charge|[payer_MOLINA MYCARE MEDICARE]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes|[payer_MOLINA MYCARE MEDICARE]|[plan_MANAGED MEDICARE] standard_charge|[payer_NGS AMERICAN INSURANCE]|[plan_COMMERCIAL]|negotiated_dollar standard_charge|[payer_NGS AMERICAN INSURANCE]|[plan_COMMERCIAL]| negotiated_percentage standard_charge|[payer_NGS AMERICAN INSURANCE]|[plan_COMMERCIAL]|negotiated_algorithm estimated_amount|[payer_NGS AMERICAN INSURANCE]|[plan_COMMERCIAL] standard_charge|[payer_NGS AMERICAN INSURANCE]|[plan_COMMERCIAL] |methodology additional_payer_notes|[payer_NGS AMERICAN INSURANCE]|[plan_COMMERCIAL] standard_charge|[payer_OHIO HEALTHY]|[plan_COMMERCIAL]|negotiated_dollar standard_charge|[payer_OHIO HEALTHY]|[plan_COMMERCIAL]| negotiated_percentage standard_charge|[payer_OHIO HEALTHY]|[plan_COMMERCIAL]|negotiated_algorithm estimated_amount|[payer_OHIO HEALTHY]|[plan_COMMERCIAL] standard_charge|[payer_OHIO HEALTHY]|[plan_COMMERCIAL] |methodology additional_payer_notes|[payer_OHIO HEALTHY]|[plan_COMMERCIAL] standard_charge|[payer_OHIO PPO CONNECT]|[plan_COMMERCIAL]|negotiated_dollar standard_charge|[payer_OHIO PPO CONNECT]|[plan_COMMERCIAL]| negotiated_percentage standard_charge|[payer_OHIO PPO CONNECT]|[plan_COMMERCIAL]|negotiated_algorithm estimated_amount|[payer_OHIO PPO CONNECT]|[plan_COMMERCIAL] standard_charge|[payer_OHIO PPO CONNECT]|[plan_COMMERCIAL] |methodology additional_payer_notes|[payer_OHIO PPO CONNECT]|[plan_COMMERCIAL] standard_charge|[payer_OHIO RISE AETNA]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_OHIO RISE AETNA]|[plan_MANAGED MEDICAID]| negotiated_percentage standard_charge|[payer_OHIO RISE AETNA]|[plan_MANAGED MEDICAID]|negotiated_algorithm estimated_amount|[payer_OHIO RISE AETNA]|[plan_MANAGED MEDICAID] standard_charge|[payer_OHIO RISE AETNA]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes|[payer_OHIO RISE AETNA]|[plan_MANAGED MEDICAID] standard_charge|[payer_OPTUM]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_OPTUM]|[plan_HMO/PPO]| negotiated_percentage standard_charge|[payer_OPTUM]|[plan_HMO/PPO]|negotiated_algorithm estimated_amount|[payer_OPTUM]|[plan_HMO/PPO] standard_charge|[payer_OPTUM]|[plan_HMO/PPO] |methodology additional_payer_notes|[payer_OPTUM]|[plan_HMO/PPO] standard_charge|[payer_PARAMOUNT MCD]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_PARAMOUNT MCD]|[plan_MANAGED MEDICAID]| negotiated_percentage standard_charge|[payer_PARAMOUNT MCD]|[plan_MANAGED MEDICAID]|negotiated_algorithm estimated_amount|[payer_PARAMOUNT MCD]|[plan_MANAGED MEDICAID] standard_charge|[payer_PARAMOUNT MCD]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes|[payer_PARAMOUNT MCD]|[plan_MANAGED MEDICAID] standard_charge|[payer_UHC COMMERICAL]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_UHC COMMERICAL]|[plan_HMO/PPO]| negotiated_percentage standard_charge|[payer_UHC COMMERICAL]|[plan_HMO/PPO]|negotiated_algorithm estimated_amount|[payer_UHC COMMERICAL]|[plan_HMO/PPO] standard_charge|[payer_UHC COMMERICAL]|[plan_HMO/PPO] |methodology additional_payer_notes|[payer_UHC COMMERICAL]|[plan_HMO/PPO] standard_charge|[payer_UHC COMMERICAL NON HMO]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_UHC COMMERICAL NON HMO]|[plan_HMO/PPO]| negotiated_percentage standard_charge|[payer_UHC COMMERICAL NON HMO]|[plan_HMO/PPO]|negotiated_algorithm estimated_amount|[payer_UHC COMMERICAL NON HMO]|[plan_HMO/PPO] standard_charge|[payer_UHC COMMERICAL NON HMO]|[plan_HMO/PPO] |methodology additional_payer_notes|[payer_UHC COMMERICAL NON HMO]|[plan_HMO/PPO] standard_charge|[payer_UHCCP MEDICAID]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_UHCCP MEDICAID]|[plan_MANAGED MEDICAID]| negotiated_percentage standard_charge|[payer_UHCCP MEDICAID]|[plan_MANAGED MEDICAID]|negotiated_algorithm estimated_amount|[payer_UHCCP MEDICAID]|[plan_MANAGED MEDICAID] standard_charge|[payer_UHCCP MEDICAID]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes|[payer_UHCCP MEDICAID]|[plan_MANAGED MEDICAID] standard_charge|[payer_UMR]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_UMR]|[plan_HMO/PPO]| negotiated_percentage standard_charge|[payer_UMR]|[plan_HMO/PPO]|negotiated_algorithm estimated_amount|[payer_UMR]|[plan_HMO/PPO] standard_charge|[payer_UMR]|[plan_HMO/PPO] |methodology additional_payer_notes|[payer_UMR]|[plan_HMO/PPO] additional_generic_notes ROOM AND BOARD PSYCH ADOL-CEN1 124 RC facility inpatient 4000 750 927 4000 927 per diem 974 per diem 974 per diem 974 per diem 950 per diem 950 per diem 975 per diem 1352 per diem 1000 per diem 4000 per diem 1154 per diem 1120 per diem ROOM AND BOARD PSYCH ADOL-WES4 124 RC facility inpatient 4000 750 927 4000 927 per diem 974 per diem 974 per diem 974 per diem 950 per diem 950 per diem 975 per diem 1352 per diem 1000 per diem 4000 per diem 1154 per diem 1120 per diem ROOM AND BOARD PSYCH ADULT CEN4 124 RC facility inpatient 4000 750 927 4000 927 per diem 974 per diem 974 per diem 974 per diem 950 per diem 950 per diem 975 per diem 1352 per diem 1000 per diem 4000 per diem 1154 per diem 1120 per diem ROOM AND BOARD PSYCH ADULT-CEN2 124 RC facility inpatient 4000 750 927 4000 927 per diem 974 per diem 974 per diem 974 per diem 950 per diem 950 per diem 975 per diem 1352 per diem 1000 per diem 4000 per diem 1154 per diem 1120 per diem ROOM AND BOARD PSYCH ADULT-WES3 124 RC facility inpatient 4000 750 927 4000 927 per diem 974 per diem 974 per diem 974 per diem 950 per diem 950 per diem 975 per diem 1352 per diem 1000 per diem 4000 per diem 1154 per diem 1120 per diem ROOM AND BOARD PSYCH WES4 124 RC facility inpatient 4000 750 927 4000 927 per diem 974 per diem 974 per diem 974 per diem 950 per diem 950 per diem 975 per diem 1352 per diem 1000 per diem 4000 per diem 1154 per diem 1120 per diem 1:1 SUPERVISION 124 RC facility inpatient 28 750 927 4000 927 per diem 974 per diem 974 per diem 974 per diem 950 per diem 950 per diem 975 per diem 1352 per diem 1000 per diem 4000 per diem 1154 per diem 1120 per diem ROOM AND BOARD DETOX ADULT-CEN2 126 RC facility inpatient 4000 750 824 4000 824 per diem 974 per diem 974 per diem 974 per diem 950 per diem 950 per diem 975 per diem 1352 per diem 1000 per diem 4000 per diem 1154 per diem 1057 per diem ROOM AND BOARD DETOX ADULT-WES3 126 RC facility inpatient 4000 750 824 4000 824 per diem 974 per diem 974 per diem 974 per diem 950 per diem 950 per diem 975 per diem 1352 per diem 1000 per diem 4000 per diem 1154 per diem 1057 per diem ROOM AND BOARD DETOX CEN4 126 RC facility inpatient 4000 750 824 4000 824 per diem 974 per diem 974 per diem 974 per diem 950 per diem 950 per diem 975 per diem 1352 per diem 1000 per diem 4000 per diem 1154 per diem 1057 per diem ROOM AND BOARD DETOX CEN4 126 RC facility inpatient 4000 750 824 4000 824 per diem 974 per diem 974 per diem 974 per diem 950 per diem 950 per diem 975 per diem 1352 per diem 1000 per diem 4000 per diem 1154 per diem 1057 per diem R&D DETOX WES4 126 RC facility inpatient 4000 750 824 4000 824 per diem 974 per diem 974 per diem 974 per diem 950 per diem 950 per diem 975 per diem 1352 per diem 1000 per diem 4000 per diem 1154 per diem 1057 per diem ROOM AND BOARD REHAB WES4 128 RC facility inpatient 4000 715 1352 824 per diem 974 per diem 974 per diem 950 per diem 715 per diem 1352 per diem 950 per diem ROOM AND BOARD REHAB/CD-CEN2 128 RC facility inpatient 4000 715 1352 824 per diem 974 per diem 974 per diem 950 per diem 715 per diem 1352 per diem 950 per diem ROOM AND BOARD REHAB/CD-WES3 128 RC facility inpatient 4000 715 1352 824 per diem 974 per diem 974 per diem 950 per diem 715 per diem 1352 per diem 950 per diem REHAB ROOM AND BOARD CEN4 128 RC facility inpatient 4000 715 1352 824 per diem 974 per diem 974 per diem 950 per diem 715 per diem 1352 per diem 950 per diem INTENSIVE OUTPATIENT PROGRAM ADOLESCENT 905 RC facility outpatient 600 150 146 1000 450 per diem 183 per diem 183 per diem 205 per diem 200 per diem 200 per diem 205 per diem 205 per diem 250 per diem 192 per diem 183 per diem 183 per diem 230 per diem 230 per diem 239 per diem 225 per diem 183 per diem 364 per diem 600 per diem 350 per diem 146 per diem 1000 per diem 1000 per diem 183 per diem 1000 per diem 1000 per diem 1000 per diem 183 per diem 309 per diem 183 per diem 309 per diem 309 per diem 183 per diem 309 per diem INTENSIVE OUTPATIENT PROGRAM GROUP 1 905 RC facility outpatient 600 150 146 1000 450 per diem 183 per diem 183 per diem 205 per diem 200 per diem 200 per diem 205 per diem 205 per diem 250 per diem 192 per diem 183 per diem 183 per diem 230 per diem 230 per diem 239 per diem 225 per diem 183 per diem 364 per diem 600 per diem 350 per diem 146 per diem 1000 per diem 1000 per diem 183 per diem 1000 per diem 1000 per diem 1000 per diem 183 per diem 309 per diem 183 per diem 309 per diem 309 per diem 183 per diem 309 per diem INTENSIVE OUTPATIENT PROGRAM PSYCH ADULT 1 905 RC facility outpatient 600 150 146 1000 450 per diem 183 per diem 183 per diem 205 per diem 200 per diem 200 per diem 205 per diem 205 per diem 250 per diem 192 per diem 183 per diem 183 per diem 230 per diem 230 per diem 239 per diem 225 per diem 183 per diem 364 per diem 600 per diem 350 per diem 146 per diem 1000 per diem 1000 per diem 183 per diem 1000 per diem 1000 per diem 1000 per diem 183 per diem 309 per diem 183 per diem 309 per diem 309 per diem 183 per diem 309 per diem PARTIAL HOSPITAL PROGRAM PSYCH ED 1 912 RC facility outpatient 250 300 374 520 425 per diem 374 per diem 374 per diem 374 per diem 430 per diem 440 per diem 520 per diem 500 per diem 400 per diem 400 per diem PARTIAL HOSPITAL PROGRAM PSYCH THERAPY 1 912 RC facility outpatient 250 300 374 520 425 per diem 374 per diem 374 per diem 374 per diem 430 per diem 440 per diem 520 per diem 500 per diem 400 per diem 400 per diem INITIAL HOSPITAL INPATIENT CARE 99221 RC facility both 200 38 71 38 fee schedule 38 fee schedule 71 fee schedule 38 fee schedule INITIAL HOSPITAL INPATIENT CARE 99222 RC facility both 210 56 107 56 fee schedule 56 fee schedule 59 fee schedule 56 fee schedule 56 fee schedule 107 fee schedule 56 fee schedule INITIAL HOSPITAL INPATIENT CARE 99223 RC facility both 250 77 219 77 fee schedule 77 fee schedule 142 fee schedule 77 fee schedule 219 fee schedule 155 fee schedule 149 fee schedule 120 fee schedule 77 fee schedule 142 fee schedule 140 fee schedule 148 fee schedule SUBSEQUENT HOSPITAL INPATIENT CARE 99231 RC facility both 120 17 69 17 fee schedule 17 fee schedule 48 fee schedule 17 fee schedule 34 fee schedule 39 fee schedule 17 fee schedule 41 fee schedule 69 fee schedule LEVEL 2 HOSPITAL SUBSEQUENT CARE 99232 RC facility both 140 25 73 28 fee schedule 28 fee schedule 29 fee schedule 68 fee schedule 28 fee schedule 25 fee schedule 51 fee schedule 52 fee schedule 28 fee schedule 65 fee schedule 61 fee schedule 28 fee schedule 73 fee schedule LEVEL 3 HOSPITAL SUBSEQUENT CARE 99233 RC facility both 160 36 97 40 fee schedule 40 fee schedule 40 fee schedule 40 fee schedule 36 fee schedule 77 fee schedule 63 fee schedule 40 fee schedule 97 fee schedule 87 fee schedule 40 fee schedule HOSPITAL INPATIENT CARE DISCHARGE 99238 RC facility both 160 32 69 53 fee schedule 32 fee schedule 69 fee schedule HOSPITAL INPATIENT CARE DISCHARGE 99239 RC facility both 200 38 98 42 fee schedule 42 fee schedule 43 fee schedule 42 fee schedule 38 fee schedule 78 fee schedule 75 fee schedule 42 fee schedule 93 fee schedule 76 fee schedule 42 fee schedule 98 fee schedule