"hospital_Belmont Behavioral Hospital, LLC " last_updated_ 2023-12-31 version_1 "hospital_Philadelphia, Pennsylvania" hospital_address 4200 Monument Road license_ 141610| PA "To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded in this machine-readable file is true, accurate, and complete as of the date indicated in this file" 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 |Commercial] standard_charge|[payer_AETNA |Commercial] |percent standard_charge|[payer_AETNA |Commercial] |contracting_method additional_payer_notes |[payer_AETNA |Commercial] standard_charge|[payer_Aetna Better Health |Medicaid] standard_charge|[payer_Aetna Better Health |Medicaid] |percent standard_charge|[payer_Aetna Better Health |Medicaid] |contracting_method additional_payer_notes |[payer_Aetna Better Health |Medicaid] standard_charge|[payer_AETNA | Medicare] standard_charge|[payer_AETNA | Medicare] |percent standard_charge|[payer_AETNA | Medicare] |contracting_method additional_payer_notes |[payer_AETNA | Medicare] standard_charge|[payer_Allwell |Medicare] standard_charge|[payer_Allwell |Medicare] |percent standard_charge|[payer_Allwell |Medicare] |contracting_method additional_payer_notes |[payer_Allwell |Medicare] standard_charge|[payer_Allied |Commercial] standard_charge|[payer_Allied |Commercial] |percent standard_charge|[payer_Allied |Commercial] |contracting_method additional_payer_notes |[payer_Allied |Commercial] standard_charge|[payer_Ambetter |Medicare] standard_charge|[payer_Ambetter |Medicare] |percent standard_charge|[payer_Ambetter |Medicare] |contracting_method additional_payer_notes |[payer_Ambetter |Medicare] standard_charge|[payer_CBH |Managed Medicaid] standard_charge|[payer_CBH |Managed Medicaid] |percent standard_charge|[payer_CBH |Managed Medicaid] |contracting_method additional_payer_notes |[payer_CBH |Managed Medicaid] standard_charge|[payer_CBHNP |Managed Medicaid] standard_charge|[payer_CBHNP |Managed Medicaid] |percent standard_charge|[payer_CBHNP |Managed Medicaid] |contracting_method additional_payer_notes |[payer_CBHNP |Managed Medicaid] standard_charge|[payer_CCBH ALLEGHENY |Managed Medicaid] standard_charge|[payer_CCBH ALLEGHENY |Managed Medicaid] |percent standard_charge|[payer_CCBH ALLEGHENY |Managed Medicaid] |contracting_method additional_payer_notes |[payer_CCBH ALLEGHENY |Managed Medicaid] standard_charge|[payer_CCBH BERKS | Managed Medicaid] standard_charge|[payer_CCBH BERKS | Managed Medicaid] |percent standard_charge|[payer_CCBH BERKS | Managed Medicaid] |contracting_method additional_payer_notes |[payer_CCBH BERKS | Managed Medicaid] standard_charge|[payer_CCBH CARBON/PIKE/MONROE |Managed Medicaid] standard_charge|[payer_CCBH CARBON/PIKE/MONROE |Managed Medicaid] |percent standard_charge|[payer_CCBH CARBON/PIKE/MONROE |Managed Medicaid] |contracting_method additional_payer_notes |[payer_CCBH CARBON/PIKE/MONROE |Managed Medicaid] standard_charge|[payer_CCBH CHESTER |Managed Medicaid] standard_charge|[payer_CCBH CHESTER |Managed Medicaid] |percent standard_charge|[payer_CCBH CHESTER |Managed Medicaid] |contracting_method additional_payer_notes |[payer_CCBH CHESTER |Managed Medicaid] standard_charge|[payer_CCBH DELAWARE | Managed Medicaid] standard_charge|[payer_CCBH DELAWARE | Managed Medicaid] |percent standard_charge|[payer_CCBH DELAWARE | Managed Medicaid] |contracting_method additional_payer_notes |[payer_CCBH DELAWARE | Managed Medicaid] standard_charge|[payer_CCBH LYCOMING/CLINTON |Managed Medicaid] standard_charge|[payer_CCBH LYCOMING/CLINTON |Managed Medicaid] |percent standard_charge|[payer_CCBH LYCOMING/CLINTON |Managed Medicaid] |contracting_method additional_payer_notes |[payer_CCBH LYCOMING/CLINTON |Managed Medicaid] standard_charge|[payer_CCBH NORTHCENTRAL | Managed Medicaid] standard_charge|[payer_CCBH NORTHCENTRAL | Managed Medicaid] |percent standard_charge|[payer_CCBH NORTHCENTRAL | Managed Medicaid] |contracting_method additional_payer_notes |[payer_CCBH NORTHCENTRAL | Managed Medicaid] standard_charge|[payer_CCBH NORTHEAST | Managed Medicaid] standard_charge|[payer_CCBH NORTHEAST | Managed Medicaid] |percent standard_charge|[payer_CCBH NORTHEAST | Managed Medicaid] |contracting_method additional_payer_notes |[payer_CCBH NORTHEAST | Managed Medicaid] standard_charge|[payer_CCBH SOMERSET/BEDFORD | Managed Medicaid] standard_charge|[payer_CCBH SOMERSET/BEDFORD | Managed Medicaid] |percent standard_charge|[payer_CCBH SOMERSET/BEDFORD | Managed Medicaid] |contracting_method additional_payer_notes |[payer_CCBH SOMERSET/BEDFORD | Managed Medicaid] standard_charge|[payer_CCBH YORK/ADAMS |Managed Medicaid] standard_charge|[payer_CCBH YORK/ADAMS |Managed Medicaid] |percent standard_charge|[payer_CCBH YORK/ADAMS |Managed Medicaid] |contracting_method additional_payer_notes |[payer_CCBH YORK/ADAMS |Managed Medicaid] standard_charge|[payer_Cigna |Commercial] standard_charge|[payer_Cigna |Commercial] |percent standard_charge|[payer_Cigna |Commercial] |contracting_method additional_payer_notes |[payer_Cigna |Commercial] standard_charge|[payer_Cigna HS | Medicare] standard_charge|[payer_Cigna HS | Medicare] |percent standard_charge|[payer_Cigna HS | Medicare] |contracting_method additional_payer_notes |[payer_Cigna HS | Medicare] standard_charge|[payer_Compsych| Commercial] standard_charge|[payer_Compsych| Commercial] |percent standard_charge|[payer_Compsych| Commercial] |contracting_method additional_payer_notes |[payer_Compsych| Commercial] standard_charge|[payer_Coresource |Commercial] standard_charge|[payer_Coresource |Commercial] |percent standard_charge|[payer_Coresource |Commercial] |contracting_method additional_payer_notes |[payer_Coresource |Commercial] standard_charge|[payer_Geisinger| Medicare] standard_charge|[payer_Geisinger| Medicare] |percent standard_charge|[payer_Geisinger| Medicare] |contracting_method additional_payer_notes |[payer_Geisinger| Medicare] standard_charge|[payer_Gateway |Medicare] standard_charge|[payer_Gateway |Medicare] |percent standard_charge|[payer_Gateway |Medicare] |contracting_method additional_payer_notes |[payer_Gateway |Medicare] standard_charge|[payer_Health Partners | Medicare] standard_charge|[payer_Health Partners | Medicare] |percent standard_charge|[payer_Health Partners | Medicare] |contracting_method additional_payer_notes |[payer_Health Partners | Medicare] standard_charge|[payer_Humana |Medicare] standard_charge|[payer_Humana |Medicare] |percent standard_charge|[payer_Humana |Medicare] |contracting_method additional_payer_notes |[payer_Humana |Medicare] standard_charge|[payer_IBC| MEDICARE ] standard_charge|[payer_IBC| MEDICARE ] |percent standard_charge|[payer_IBC| MEDICARE ] |contracting_method additional_payer_notes |[payer_IBC| MEDICARE ] standard_charge|[payer_IBC |Commercial] standard_charge|[payer_IBC |Commercial] |percent standard_charge|[payer_IBC |Commercial] |contracting_method additional_payer_notes |[payer_IBC |Commercial] standard_charge|[payer_Keystone VIP | Medicare] standard_charge|[payer_Keystone VIP | Medicare] |percent standard_charge|[payer_Keystone VIP | Medicare] |contracting_method additional_payer_notes |[payer_Keystone VIP | Medicare] standard_charge|[payer_KIDZ PARTNERS| Medicaid] standard_charge|[payer_KIDZ PARTNERS| Medicaid] |percent standard_charge|[payer_KIDZ PARTNERS| Medicaid] |contracting_method additional_payer_notes |[payer_KIDZ PARTNERS| Medicaid] standard_charge|[payer_LEHIGH/NORTHAMPTON| Managed Medicaid] standard_charge|[payer_LEHIGH/NORTHAMPTON| Managed Medicaid] |percent standard_charge|[payer_LEHIGH/NORTHAMPTON| Managed Medicaid] |contracting_method additional_payer_notes |[payer_LEHIGH/NORTHAMPTON| Managed Medicaid] standard_charge|[payer_Magellan Bucks| Managed Medicaid] standard_charge|[payer_Magellan Bucks| Managed Medicaid] |percent standard_charge|[payer_Magellan Bucks| Managed Medicaid] |contracting_method additional_payer_notes |[payer_Magellan Bucks| Managed Medicaid] standard_charge|[payer_Medicaid | Medicaid] standard_charge|[payer_Medicaid | Medicaid] |percent standard_charge|[payer_Medicaid | Medicaid] |contracting_method additional_payer_notes |[payer_Medicaid | Medicaid] standard_charge|[payer_Medicare |Medicare ] standard_charge|[payer_Medicare |Medicare ] |percent standard_charge|[payer_Medicare |Medicare ] |contracting_method additional_payer_notes |[payer_Medicare |Medicare ] standard_charge|[payer_MERCY LIFE| Medicare] standard_charge|[payer_MERCY LIFE| Medicare] |percent standard_charge|[payer_MERCY LIFE| Medicare] |contracting_method additional_payer_notes |[payer_MERCY LIFE| Medicare] standard_charge|[payer_Meritain |Commercial] standard_charge|[payer_Meritain |Commercial] |percent standard_charge|[payer_Meritain |Commercial] |contracting_method additional_payer_notes |[payer_Meritain |Commercial] standard_charge|[payer_MH Consultants| Commercial] standard_charge|[payer_MH Consultants| Commercial] |percent standard_charge|[payer_MH Consultants| Commercial] |contracting_method additional_payer_notes |[payer_MH Consultants| Commercial] standard_charge|[payer_MHNET |Commercial] standard_charge|[payer_MHNET |Commercial] |percent standard_charge|[payer_MHNET |Commercial] |contracting_method additional_payer_notes |[payer_MHNET |Commercial] "standard_charge|[payer_Montgomery| Managed Medicaid]" "standard_charge|[payer_Montgomery| Managed Medicaid] |percent" "standard_charge|[payer_Montgomery| Managed Medicaid] |contracting_method" "additional_payer_notes |[payer_Montgomery| Managed Medicaid]" standard_charge|[payer_New Courtland Life |Medicare] standard_charge|[payer_New Courtland Life |Medicare] |percent standard_charge|[payer_New Courtland Life |Medicare] |contracting_method additional_payer_notes |[payer_New Courtland Life |Medicare] standard_charge|[payer_Quest Behavioral Health | Commercial] standard_charge|[payer_Quest Behavioral Health | Commercial] |percent standard_charge|[payer_Quest Behavioral Health | Commercial] |contracting_method additional_payer_notes |[payer_Quest Behavioral Health | Commercial] standard_charge|[payer_Tricare/VA |Tricare] standard_charge|[payer_Tricare/VA |Tricare] |percent standard_charge|[payer_Tricare/VA |Tricare] |contracting_method additional_payer_notes |[payer_Tricare/VA |Tricare] standard_charge|[payer_UBH/UMR | Commercial] standard_charge|[payer_UBH/UMR | Commercial] |percent standard_charge|[payer_UBH/UMR | Commercial] |contracting_method additional_payer_notes |[payer_UBH/UMR | Commercial] standard_charge|[payer_UHC |MEDICARE] standard_charge|[payer_UHC |MEDICARE] |percent standard_charge|[payer_UHC |MEDICARE] |contracting_method additional_payer_notes |[payer_UHC |MEDICARE] standard_charge|[payer_UPMC for Life | Medicare] standard_charge|[payer_UPMC for Life | Medicare] |percent standard_charge|[payer_UPMC for Life | Medicare] |contracting_method additional_payer_notes |[payer_UPMC for Life | Medicare] standard_charge|[payer_UPMC HP | Commercial ] standard_charge|[payer_UPMC HP | Commercial ] |percent standard_charge|[payer_UPMC HP | Commercial ] |contracting_method additional_payer_notes |[payer_UPMC HP | Commercial ] standard_charge|[payer_UPMC |Medicaid] standard_charge|[payer_UPMC |Medicaid] |percent standard_charge|[payer_UPMC |Medicaid] |contracting_method additional_payer_notes |[payer_UPMC |Medicaid] standard_charge|[payer_Value Options |Commercial] standard_charge|[payer_Value Options |Commercial] |percent standard_charge|[payer_Value Options |Commercial] |contracting_method additional_payer_notes |[payer_Value Options |Commercial] Room and Board all Inclusive Per-Diem 124 RC facility Inpatient " 2,600 " 660.00 624 " 1,400 " " 1,332 " per diem 660 per diem " 1,293 " per diem Medicare Rate " 1,000 " per diem Medicare Rate 850 per diem 659 per diem 787 per diem 729 per diem 750 per diem 880 per diem 817 per diem 737 per diem 754 per diem " 1,065 " per diem Medicare Rate Medicare Rate " 1,400 " " 1,231 " Medicare Rate Medicare Rate 867 per diem " 1,151 " per diem 900 per diem " 1,290 " per diem " 1,290 " per diem Medicare Rate Medicare Rate 880 per diem 880 per diem 624 per diem Medicare Rate Medicare Rate Medicare Rate Medicare Rate " 1,293 " per diem 800 per diem " 1,175 " per diem 880 per diem Medicare Rate Medicare Rate " 1,034 " per diem Medicare Rate Medicare Rate 908 per diem 908 per diem 868 per diem 868 per diem Room and Board all Inclusive Per-Diem Child / Adol 114 RC facility Inpatient " 2,600 " 660.00 624 " 1,400 " " 1,332 " per diem 660 per diem " 1,050 " per diem " 1,000 " per diem 659 per diem 853 per diem 760 per diem 813 per diem 880 per diem 899 per diem 748 per diem 836 per diem " 1,065 " per diem " 1,400 " " 1,231 " " 1,350 " per diem " 1,151 " per diem 880 per diem 880 per diem 624 per diem " 1,293 " per diem 800 per diem " 1,175 " per diem 880 per diem " 1,034 " per diem 908 per diem 868 per diem Room and Board STAR Single Room 144 RC facility Inpatient " 2,600 " 0.00 " 1,700 " " 2,875 " " 1,700 " per diem " 2,875 " per diem " 2,530 " per diem " 2,484 " per diem " 2,300 " per diem " 2,300 " per diem " 2,300 " per diem " 1,900 " per diem " 1,900 " per diem Room and Board STAR Double Room 140 RC facility Inpatient " 2,600 " 0.00 " 1,700 " " 2,375 " " 1,700 " per diem " 2,375 " per diem " 2,090 " per diem " 2,052 " per diem " 1,900 " per diem " 1,900 " per diem " 1,900 " per diem " 1,900 " per diem " 1,900 " per diem ELECTOCONVULSIVE THERAPY 901 RC facility Inpatient and Outpatient " 1,281 " 0.00 42 988 986 per diem 986 per diem 850 per diem 793 per diem 300 per diem 635 per diem 635 per diem 588 per diem 450 per diem 430 per diem 661 per diem 695 per diem 526 per diem 820 894 471 per diem 650 per diem 761 per diem 499 per diem 837 per diem 837 per diem 471 per diem 133 per diem 450 per diem 425 per diem 42 per diem 499 per diem 499 per diem 939 per diem 575 per diem 831 per diem 450 per diem 471 per diem 988 per diem 507 per diem 693 per diem 666 per diem 588 per diem 588 per diem 588 per diem 131 per diem ESTAB OFF VISIT 15 99212 RC facility Outpatient 119 75.00 32 98 68 per diem 32 per diem 82 per diem 55 per diem 56 per diem 98 per diem 60 42 71 per diem 98 per diem 55 per diem 63 per diem 59 per diem 78 per diem 71 per diem 55 per diem 44 per diem 35 per diem 55 per diem 95 per diem 80 per diem 60 per diem 80 per diem 72 per diem 98 per diem 80 per diem 81 per diem 70 per diem 70 per diem 98 per diem 75 per diem 75 per diem 38 per diem ESTAB OFF VISIT 30 99213 RC facility Outpatient 238 0.00 43 176 100 per diem 54 per diem 117 per diem 55 per diem 176 per diem 129 per diem 103 72 102 per diem 139 per diem 59 per diem 87 per diem 83 per diem 84 per diem 102 per diem 59 per diem 54 per diem 85 per diem 117 per diem 80 per diem 78 per diem 83 per diem 117 per diem 84 per diem 88 per diem 88 per diem 139 per diem 92 per diem 92 per diem 43 per diem ESTAB OFF VISIT 45 99214 RC facility Outpatient 356 0.00 78 197 87 per diem 78 per diem 197 per diem 197 per diem 128 per diem 157 per diem 193 per diem 79 per diem 116 per diem 124 per diem 79 per diem 78 per diem 87 per diem 100 per diem 128 per diem 119 per diem 88 per diem 106 per diem 110 per diem 110 per diem 110 per diem 95 per diem INTENSIVE OUTPATIENT PROGRAM DAILY 915 RC facility Outpatient 810 275.00 120 750 336 per diem 10 per diem 511 per diem 350 per diem 255 per diem 249 per diem 275 305 257 per diem 249 per diem 239 per diem 334 per diem 334 per diem 257 per diem 304 per diem 235 per diem 239 per diem 305 per diem 150 per diem 248 per diem 265 per diem 239 per diem 202 per diem 202 per diem 120 per diem 750 per diem 200 per diem PARTIAL HOSPITAL PROGRAM C&A CBH Billed 912 RC facility Outpatient 270 0.00 70 190 118 per diem 114 per diem 190 per diem 70 per diem PARTIAL HOSPITAL PROGRAM CBH ACUTE 912 RC facility Outpatient 270 0.00 109 109 109 per diem PARTIAL HOSPITAL PROGRAM CBH INTERM 912 RC facility Outpatient 270 0.00 97 97 97 per diem PARTIAL HOSPITAL PROGRAM CBH SUBACUTE 912 RC facility Outpatient 270 100.00 53 53 53 per diem PARTIAL HOSPITAL PROGRAM DAILY 912 RC facility Outpatient " 1,080 " 375.00 220 " 1,000 " 511 per diem 10 per diem 511 per diem 400 per diem 237 per diem 400 per diem 281 per diem 567 442 280 per diem 252 per diem 455 per diem 455 per diem 280 per diem 456 per diem 250 per diem 220 per diem 276 per diem 276 per diem 442 per diem 375 per diem 418 per diem 231 per diem 232 per diem 398 per diem 282 per diem 270 per diem 270 per diem " 1,000 " per diem 292 per diem PSYCH EVAL CBH 90871 RC facility Outpatient 296 150.00 104 104 104 per diem TRANSCRANIAL MAGNETIC STIMULATION Initial 90867 RC facility Inpatient and Outpatient 778 150.00 158 622 600 fee schedule 329 fee schedule 481 fee schedule 622 fee schedule 276 fee schedule 450 313 294 fee schedule 261 fee schedule 428 fee schedule 158 fee schedule 421 fee schedule 294 fee schedule 428 fee schedule 600 fee schedule 289 fee schedule 289 fee schedule 298 fee schedule 600 fee schedule 261 fee schedule 350 fee schedule 276 fee schedule 275 fee schedule 600 fee schedule 600 fee schedule TRANSCRANIAL MAGNETIC STIMULATION Motor Threshold 90869 RC facility Inpatient and Outpatient 778 360.00 132 622 600 fee schedule 408 fee schedule 481 fee schedule 622 fee schedule 276 fee schedule 375 343 294 fee schedule 141 fee schedule 428 fee schedule 132 fee schedule 421 fee schedule 294 fee schedule 428 fee schedule 600 fee schedule 289 fee schedule 289 fee schedule 327 fee schedule 600 fee schedule 276 fee schedule 265 fee schedule 146 fee schedule 275 fee schedule 600 fee schedule 600 fee schedule TRANSCRANIAL MAGNETIC STIMULATION Subsequent Treatment 60868 RC facility Inpatient and Outpatient 518 300.00 31 421 400 fee schedule 400 fee schedule 250 fee schedule 414 fee schedule 276 fee schedule 297 408 294 fee schedule 141 fee schedule 213 fee schedule 31 fee schedule 421 fee schedule 294 fee schedule 213 fee schedule 400 fee schedule 289 fee schedule 289 fee schedule 389 fee schedule 400 fee schedule 141 fee schedule 265 fee schedule 276 fee schedule 275 fee schedule 400 fee schedule 400 fee schedule 400 fee schedule