NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT-OF-STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/15 - 03/31/15
Hospital Name
AKRON GENERAL MEDICAL CENTER
ALAMANCE REG MED CTR NC
ALEGENT HLTH BERGAN MERCY NE
ALFRED I DUPONT HOSP FOR CHID
ALL CHILDRENS HOSPITAL FL
ALLEGHENY GENERAL HOSPITAL PA
ALLEGIANCE HLTH/W A FOOT MEM
ALLINA HLTH SYS/MERCY HSP MN
ATHENS REG MED TN
ATLANTIC GEN HSP MD
ATLANTICARE REG MED CTR CITY
AULTMAN HOSPITAL OH
AVENTURA HOSP & MED CTR FL
BALTIMORE WASHINGTON MEDICAL
BANNER BAYWOOD MED CTR AZ
BANNER DEL E WEBB MEM HSP AZ
BANNER IRONWOOD MED CTR AZ
BANNER THUNDERBIRD MED CTR AZ
BAPTIST ST ANTHONYS MEM HOSP
BARNES-KASSON COUNTY HSP
BARTON MEMORIAL HOSPITAL CA
BAY COUNTY HEALTH SYSTEM FL
BAYHEALTH KENT GEN HSP DE
BAYLOR MED CTR GARLAND TX
BAYLOR MED CTR MCKINNEY TX
BAYLOR UNIVERSITY MED CTR TX
BAYONNE MEDICAL CENTER NJ
BAYSHORE COMMUNITY HOSPITAL
BAYSTATE MEDICAL CENTER MA
BELLEVUE MEDICAL CENTER NE
BERGEN PINES COUNTY HSP NJ
BERKSHIRE HEALTH SYSTEM MA
BERKSHIRE MEDICAL CTR MA INC
BETH ISRAEL DEACONESS BOSTON
BORGESS MEDICAL CENTER MI
BOSTON MEDICAL CENTER
MA
BRADFORD REGIONAL MED CTR PA
BRATTLEBORO MEM HOSPITAL VT
BRATTLEBORO RETREAT HSP VT
BRIDGEPORT HOSPITAL
BRIGHAM AND WOMENS HOSP
BRISTOL HOSPITAL
BROCKTON HOSP MA
BROOKEGLEN BEHAVIORAL HOSPITA
BROWARD GENERAL MEDICAL CTR
BRYN MAWR HOSPITAL PA
BRYN MAWR REHAB HOSP PA
CAPE CANAVERAL HOSP FL
CAPE CORAL HSP FL
CAPE FEAR VALLEY NC
CAPE REGIONAL MEDICAL CENTER
CAPITAL HEALTH SYS AT FULD
City, State
AKRON
BURLINGTON
OMAHA
WILMINGTON
ST PETERSBURG
PITTSBURGH
JACKSON
COON RAPIDS
ATHENS
BERLIN
ATLANTIC CITY
CANTON
AVENTURA
GLEN BURNIE
MESA
SUN CITY
SAN TAN VALLEY
GLENDALE
AMARILLO
SUSQUEHANNA
SOUTH LAKE TAHOE
PANAMA CITY
DOVER
GARLAND
MCKINNEY
DALLAS
BAYONNE
HOLMDEL
SPRINGFIELD
BELLEVUE
PARAMUS
PITTSFIELD
PITTSFIELD
BOSTON
KALAMAZOO
BOSTON
BRADFORD
BRATTLEBORO
BRATTLEBORO
BRIDGEPORT
BOSTON
BRISTOL
BROCKTON
FORT WASHINGTON
FT LAUDERDALE
BRYN MAWR
MALVERN
COCOA BEACH
CAPE CORAL
FAYETTEVILLE
CAPE MAY COURT HOUSE
TRENTON
OH
NC
NE
DE
FL
PA
MI
MN
TN
MD
NJ
OH
FL
MD
AZ
AZ
AZ
AZ
TX
PA
CA
FL
DE
TX
TX
TX
NJ
NJ
MA
NE
NJ
MA
MA
MA
MI
MA
PA
VT
VT
CT
MA
CT
MA
PA
FL
PA
PA
FL
FL
NC
NJ
NJ
Rate Code 2953
(OOS Hospital
DRG)
$
6,489.00
$
5,812.44
$
6,489.00
$
5,812.44
$
5,812.44
$
6,489.00
$
5,812.44
$
6,489.00
$
5,812.44
$
5,812.44
$
6,489.00
$
6,489.00
$
5,812.44
$
5,812.44
$
5,812.44
$
5,812.44
$
5,812.44
$
5,812.44
$
6,489.00
$
5,812.44
$
5,812.44
$
5,812.44
$
5,812.44
$
6,489.00
$
5,812.44
$
8,982.32
$
7,446.80
$
7,446.80
$
6,489.00
$
5,812.44
$
8,982.32
$
6,489.00
$
6,489.00
$
8,982.32
$
6,489.00
$
8,982.32
$
5,812.44
$
5,812.44
$
5,812.44
$
8,982.32
$
8,982.32
$
5,812.44
$
6,489.00
$
5,812.44
$
6,489.00
$
5,812.44
$
5,812.44
$
5,812.44
$
5,812.44
$
6,489.00
$
5,812.44
$
6,489.00
Rate Code 2952
(OOS Hospital
Exempt)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
-
Rate Code 2589
(DME Add-on)
$
463.71
$
$
463.71
$
$
$
463.71
$
$
463.71
$
$
$
463.71
$
463.71
$
$
$
$
$
$
$
463.71
$
$
$
$
$
463.71
$
$
1,395.82
$
$
$
463.71
$
$
1,395.82
$
463.71
$
463.71
$
1,395.82
$
463.71
$
1,395.82
$
$
$
$
1,395.82
$
1,395.82
$
$
463.71
$
$
463.71
$
$
$
$
$
463.71
$
$
463.71
1 of 10
Rate Code
2950 and 2954
(ALC RHCF)
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
254.96
$
254.96
$
254.96
$
187.52
$
187.52
$
254.96
$
187.52
$
187.52
$
254.96
$
187.52
$
254.96
$
187.52
$
187.52
$
187.52
$
254.96
$
254.96
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
Rate Code
2951 and 2955
(ALC Home
Care)
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
254.96
$
254.96
$
254.96
$
187.52
$
187.52
$
254.96
$
187.52
$
187.52
$
254.96
$
187.52
$
254.96
$
187.52
$
187.52
$
187.52
$
254.96
$
254.96
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
$
187.52
Rate Code 2990
(Capital per
Disch)
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
760.34
$
760.34
$
760.34
$
617.64
$
617.64
$
760.34
$
617.64
$
617.64
$
760.34
$
617.64
$
760.34
$
617.64
$
617.64
$
617.64
$
760.34
$
760.34
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
$
617.64
Rate Code 2991
(Capital per
Diem)
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
154.04
$
154.04
$
154.04
$
129.64
$
129.64
$
154.04
$
129.64
$
129.64
$
154.04
$
129.64
$
154.04
$
129.64
$
129.64
$
129.64
$
154.04
$
154.04
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
$
129.64
WEF/ISAF
(for Cost
Outlier
Claims)
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
1.0744
1.0744
0.8386
0.8386
1.0744
0.8386
0.8386
1.0744
0.8386
1.0744
0.8386
0.8386
0.8386
1.0744
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
High Cost
Charge
Convertors
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.357482
0.357482
0.442464
0.442464
0.357482
0.442464
0.442464
0.357482
0.442464
0.357482
0.442464
0.442464
0.442464
0.357482
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT-OF-STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/15 - 03/31/15
Hospital Name
CAPITAL HEALTH SYSTEM MERCER
CARILION FRANKLIN MEMORIAL VA
CARILION ROANOKE COMM HSP VA
CARILION ROANOKE MEMORIAL
CARILION STONEWALL JACKSN VA
CARLE FOUNDATION HOSP IL
CAROLINAEAST HEALTH SYSTEM
CAROLINAS HSP SYS SC
CARONDELET ST MARYS HOSP AZ
CARROLL HOSPITAL CENTER MD
CATHOLIC MED CTR NH
CENTENNIAL MED CTR TN
CENTRA VIRGINIA BAPTST HSP VA
CENTRAL VERMONT HOSPITAL
CENTRASTATE MED CTR NJ
CENTURA PENROSE ST FRANCIS HL
CHARLES COLE MEMORIAL HSP
CHARLESTON AREA MED CTR WV
CHARLOTTE HUNGERFORD HOSPITAL
CHESHIRE MEDICAL CTR NH
CHESTER COUNTY HOSP PA
CHILDRENS HOSP M C OH
CHILDRENS HOSP OF PHILA PA
CHILDRENS HOSPITAL ALABAMA
CHILDRENS HOSPITAL CO
CHILDRENS HOSPITAL MA
CHILDRENS HOSPITAL MA
CHILDRENS HOSPITAL OF PITTS
CHILDRENS HOSPITAL OF PITTS
CHILDRENS HOSPITAL SAN DIEGO
CHILDRENS HSP KINGS DAUGHTER
CHILDRENS INSTITUTE OF PITTS
CHILDRENS NATIONAL MED CTR
CHILDRENS SPECIALIZED HOSP NJ
CHRIST HOSPITAL NJ
CHRISTIANA CARE HLTH SERV DE
CITRUS MEMORIAL HOSPITAL FL
CITY HOSPITAL WV
CLARA MAASS MEM HOSP
CLARION HOSPITAL PA
CLARION PSYCHIATRIC CTR PA
CLEVELAND CLINIC FOUNDATION
COLUMBIA WESLEY MEDICAL CENTE
COMMUNITY HLTH CTR BRANCH CTY
COMMUNITY MED CTR NJ
COMMUNITY MEDICAL CENTER PA
COMMUNITY MEMORIAL HOSP VA
CONCORD HOSPITAL NH
CONEMAUGH VALLEY MEM HSP PA
CONWAY HOSPITAL SC
COOLEY DICKINSON HOSP MA
COOPER MED CTR CAMDEN NJ
City, State
TRENTON
ROCKY MOUNT
ROANOKE
ROANOKE
LEXINGTON
URBANA
NEW BERN
FLORENCE
TUCSON
WESTMINSTER
MANCHESTER
NASHVILLE
LYNCHBURG
BARRE
FREEHOLD
COLORADO SPRINGS
COUDERSPORT
CHARLESTON
TORRINGTON
KEENE
WEST CHESTER
CINCINNATI
PHILADELPHIA
BIRMINGHAM
AURORA
BOSTON
BOSTON
PITTSBURGH
PITTSBURGH
SAN DIEGO
NORFOLK
PITTSBURGH
WASHINGTON
MOUNTAINSIDE
JERSEY CITY
WILMINGTON
INVERNESS
MARTINSBURG
TOMS RIVER
CLARION
CLARION
CLEVELAND
WICHITA
COLDWATER
TOMS RIVER
SCRANTON
SOUTH HILL
CONCORD
JOHNSTOWN
CONWAY
NORTHAMPTON
CAMDEN
NJ
VA
VA
VA
VA
IL
NC
SC
AZ
MD
NH
TN
VA
VT
NJ
CO
PA
WV
CT
NH
PA
OH
PA
AL
CO
MA
MA
PA
PA
CA
VA
PA
DC
NJ
NJ
DE
FL
WV
NJ
PA
PA
OH
KS
MI
NJ
PA
VA
NH
PA
SC
MA
NJ
Rate Code 2953
(OOS Hospital
DRG)
Rate Code 2952
(OOS Hospital
Exempt)
Rate Code
Rate Code 2589 2950 and 2954
(DME Add-on)
(ALC RHCF)
Rate Code
2951 and 2955
(ALC Home
Care)
Rate Code 2990
(Capital per
Disch)
Rate Code 2991
(Capital per
Diem)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
6,489.00
5,812.44
6,489.00
5,812.44
5,812.44
5,812.44
5,812.44
5,812.44
7,446.80
5,812.44
5,812.44
7,446.80
6,489.00
5,812.44
8,982.32
6,489.00
5,812.44
6,489.00
7,446.80
5,812.44
5,812.44
5,812.44
8,982.32
5,812.44
5,812.44
8,982.32
8,982.32
6,489.00
6,489.00
8,982.32
5,812.44
5,812.44
7,446.80
8,982.32
6,489.00
5,812.44
6,489.00
5,812.44
6,489.00
5,812.44
6,489.00
5,812.44
6,489.00
5,812.44
6,489.00
5,812.44
6,489.00
6,489.00
5,812.44
5,812.44
5,812.44
1,629.26
-
2 of 10
463.71
463.71
463.71
1,395.82
463.71
463.71
1,395.82
1,395.82
1,395.82
463.71
463.71
1,395.82
1,395.82
463.71
463.71
463.71
463.71
463.71
463.71
463.71
463.71
-
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
254.96
187.52
187.52
254.96
187.52
187.52
187.52
254.96
187.52
187.52
187.52
254.96
187.52
187.52
254.96
254.96
187.52
187.52
254.96
187.52
187.52
254.96
254.96
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
254.96
187.52
187.52
254.96
187.52
187.52
187.52
254.96
187.52
187.52
187.52
254.96
187.52
187.52
254.96
254.96
187.52
187.52
254.96
187.52
187.52
254.96
254.96
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
760.34
617.64
617.64
760.34
617.64
617.64
760.34
617.64
617.64
617.64
760.34
617.64
617.64
617.64
760.34
617.64
617.64
760.34
760.34
617.64
617.64
760.34
617.64
617.64
760.34
760.34
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
129.64
129.64
154.04
129.64
129.64
154.04
129.64
129.64
129.64
154.04
129.64
129.64
129.64
154.04
129.64
129.64
154.04
154.04
129.64
129.64
154.04
129.64
129.64
154.04
154.04
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
WEF/ISAF
(for Cost
Outlier
Claims)
High Cost
Charge
Convertors
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
1.0744
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
1.0744
1.0744
0.8386
0.8386
1.0744
0.8386
0.8386
1.0744
1.0744
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.357482
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.357482
0.357482
0.442464
0.442464
0.357482
0.442464
0.442464
0.357482
0.357482
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT-OF-STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/15 - 03/31/15
Hospital Name
COPLEY HOSPITAL VT
INC
CORAL SPRINGS MEDICAL CTR FL
CORRY MEMORIAL HOSPITAL PA
CROZER-CHESTER MEDICAL CTR PA
CUMBERLAND HOSP
VA
DAMERON HOSPITAL ASSOC
DANA FARBER CANCER INSTITUTE
DANBURY HOSP CT
DAVIS HOSPITAL AND MED CTR UT
DAY KIMBALL HOSPITAL CT
DCH REGIONAL MED CTR AL
DEACONESS HOSPITAL WA
DELAWARE CTY MEMORIAL HSP PA
DELRAY MEDICAL CTR FL
DESERT REGIONAL MED CTR
DIVINE PROVIDENCE HOSP PA
DIXIE MEDICAL CENTER UT
DOCTORS COMMUNITY HOSPITAL MD
DUBOIS REG MED CTR MERCY DIV
DUKE UNIVERSITY HOSPITAL NC
DURHAM REGIONAL HOSPITAL NC
EAST JEFFERSON GEN HOSP LA
EAST ORANGE GENERAL HOSPITAL
EAST TENNESSE CHILD HOSP
EASTERN MAINE MED CTR ME
EASTON HOSPITAL PA
EMMA PENDLETON BRADLEY HSP RI
ENGLEWOOD HOSP MED CTR NJ
ERLANGER MED CTR TN
FAIRVIEW GENERAL HOSPITAL OH
FAIRVIEW HOSPITAL
FAIRVIEW UNIV MED CTR MN
FALMOUTH HOSP ASSOC MA
FLAGLER HOSPITAL FL
FLETCHER ALLEN HLTH - MCHV
FLORIDA HLTH SCI/TAMPA GEN
FLORIDA HOSP HEARTLAND FL
FLORIDA HOSP MED CTR FL
FLORIDA HOSP WATERMAN FL
FLORIDA HOSPITAL ZEPHYR HILLS
FLORIDA HSP FISH MEMORIAL FL
FRANKLIN SQUARE HOSP MD
GARDEN GROVE HOSP MC CA
GEISINGER MEDICAL CENTER PA
GEISINGER SOUTH WILKES-BARRE
GEORGETOWN UNIVERSITY HOSP DC
GETTYSBURG HOSPITAL
GNADEN HUETTEN MEM HOSP PA
GOOD SAMARITAN HOSPITAL OH
GOOD SAMARITAN HSP FL
GRADY MEMORIAL HOSPITAL
GRANDVIEW HOSPITAL OH
City, State
MORRISVILLE
CORAL SPRINGS
CORRY
UPLAND
NEW KENT
STOCKTON
BOSTON
DANBURY
LAYTON
PUTNAM
TUSCALOOSA
SPOKANE
DREXEL HILL
DELRAY BEACH
PALM SPRINGS
WILLIAMSPORT
ST GEORGE
LANHAM
DUBOIS
DURHAM
DURHAM
METAIRE
EAST ORANGE
KNOXVILLE
BANGOR
EASTON
RIVERSIDE
ENGLEWOOD
CHATTANOOGA
CLEVELAND
GT BARRINGTON
MINNEAPOLIS
FALMOUTH
ST AUGUSTINE
BURLINGTON
TAMPA
SEBRING
ORLANDO
TAVARES
ZEPHYRHILLS
ORANGE CITY
BALTIMORE
GARDEN GROVE
DANVILLE
WILKES BARRE
WASHINGTON
GETTYSBURG
LEHIGHTON
DAYTON
WEST PALM BEACH
ATLANTA
DAYTON
VT
FL
PA
PA
VA
CA
MA
CT
UT
CT
AL
WA
PA
FL
CA
PA
UT
MD
PA
NC
NC
LA
NJ
TN
ME
PA
RI
NJ
TN
OH
MA
MN
MA
FL
VT
FL
FL
FL
FL
FL
FL
MD
CA
PA
PA
DC
PA
PA
OH
FL
GA
OH
Rate Code 2953
(OOS Hospital
DRG)
Rate Code 2952
(OOS Hospital
Exempt)
Rate Code
Rate Code 2589 2950 and 2954
(DME Add-on)
(ALC RHCF)
Rate Code
2951 and 2955
(ALC Home
Care)
Rate Code 2990
(Capital per
Disch)
Rate Code 2991
(Capital per
Diem)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
5,812.44
5,812.44
5,812.44
6,489.00
5,812.44
5,812.44
7,446.80
8,982.32
5,812.44
5,812.44
6,489.00
6,489.00
6,489.00
5,812.44
6,489.00
5,812.44
5,812.44
5,812.44
5,812.44
6,489.00
6,489.00
6,489.00
7,446.80
5,812.44
6,489.00
6,489.00
5,812.44
8,982.32
6,489.00
6,489.00
5,812.44
5,812.44
5,812.44
5,812.44
7,199.87
6,489.00
5,812.44
6,489.00
5,812.44
5,812.44
5,812.44
8,982.32
5,812.44
6,489.00
6,489.00
8,982.32
6,489.00
5,812.44
6,489.00
5,812.44
6,489.00
6,489.00
-
3 of 10
463.71
1,395.82
463.71
463.71
463.71
463.71
463.71
463.71
463.71
463.71
463.71
1,395.82
463.71
463.71
1,113.19
463.71
463.71
1,395.82
463.71
463.71
1,395.82
463.71
463.71
463.71
463.71
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
187.52
187.52
187.52
187.52
187.52
187.52
254.96
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
617.64
617.64
617.64
617.64
617.64
617.64
760.34
760.34
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
760.34
617.64
617.64
617.64
617.64
760.34
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
760.34
617.64
617.64
617.64
760.34
617.64
617.64
617.64
617.64
617.64
617.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
154.04
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
129.64
129.64
129.64
129.64
154.04
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
129.64
129.64
129.64
154.04
129.64
129.64
129.64
129.64
129.64
129.64
WEF/ISAF
(for Cost
Outlier
Claims)
High Cost
Charge
Convertors
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT-OF-STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/15 - 03/31/15
Hospital Name
GREAT RIVER MEDICAL CENTER
GREATER BALTIMORE MED CTR MD
GREENWICH HOSP CT
GRIFFIN HOSPITAL CT
GROSSMONT HOSPITAL CA
GWINNETT HOSPITAL SYSTEM GA
GWINNETT MED CTR GA
HACKENSACK UNIV MED CTR NJ
HACKETTSTOWN REG MED CTR
HALIFAX MED CTR FL
HALIFAX REGIONAL HOSP VA
HAMILTON MEDICAL CENTER GA
HAMOT MEDICAL CENTER PA
HANOVER HOSPITAL PA
HARBORVIEW MED CTR WA
HARDIN MEMORIAL HOSPITAL KY
HARFORD MEMORIAL HOSP MD
HARRINGTON MEMORIAL HOSPITAL
HAZLETON GEN HSP PA
HCA OAK HILL HOSP FL
HEALTH ALLIANCE HOSP
HEALTHSOUTH REHAB HOSP ERIE
HELEN ELLIS MEM HSP FL
HENRY HEYWOOD MEM HOSP MA
HIALEAH HOSPITAL FL
HIGH POINT REG HEALTH SYS NC
HOLMES REG MED CTR FL
HOLY CROSS HSP FL
HOLY NAME HOSPITAL NJ
HOLY SPIRIT HOSPITAL
HOLYOKE HOSP MA
HOMESTEAD HOSPITAL FL
HOSPITAL CORP/LAKEVIEW HSP UT
HOSPITAL OF THE UNIV OF PENN
HOUSTON HOSPITALS INC GA
HOWARD CTY GENERAL HSP MD
HUGULEY MEMORIAL HOSPITAL TX
IMPERIAL POINT HSP FL
INTERMOUNTAIN MEDICAL CENTER
JACKSON MEM HSP FL
JERSEY CITY MEDICAL CTR NJ
JERSEY SHORE MEDICAL CTR NJ
JOHN C LINCOLN DEERVALLEY AZ
JOHN C LINCOLN HOSP HLTH AZ
JOHN DEMPSEY HOSPITAL UNIV CT
JOHN F KENNEDY MED CTR
JOHNS HOPKINS HOSPITAL MD
JOHNSON MEM HSP
JORDAN HOSPITAL INC MA
KENNEDY KRIEGER INSTITUTE MD
KENNEDY MEM HOSP/CHERRY HILL
KENNEDY MEM HOSP/UMC STRATFOR
City, State
WEST BURLINGTON
BALTIMORE
GREENWICH
DERBY
LA MESA
DULUTH
LAWRENCEVILLE
HACKENSACK
HACKETTSTOWN
DAYTONA BEACH
SOUTH BOSTON
DALTON
ERIE
HANOVER
SEATTLE
ELIZABETHTOWN
HAVRE DE GRACE
SOUTHBRIDGE
HAZLETON
BROOKSVILLE
LEOMINSTER
ERIE
TARPON SPRINGS
GARDNER
HIALEAH
HIGH POINT
MELBOURNE
FT LAUDERDALE
TEANECK
CAMP HILL
HOLYOKE
HOMESTEAD
BOUNTIFUL
PHILADELPHIA
WARNER ROBINS
COLUMBIA
FT WORTH
FT LAUDERDALE
MURRAY
MIAMI
JERSEY CITY
NEPTUNE
PHOENIX
PHOENIX
FARMINGTON
EDISON
BALTIMORE
STAFFORD SPRINGS
PLYMOUTH
BALTIMORE
CHERRY HILL
STRATFORD
IA
MD
CT
CT
CA
GA
GA
NJ
NJ
FL
VA
GA
PA
PA
WA
KY
MD
MA
PA
FL
MA
PA
FL
MA
FL
NC
FL
FL
NJ
PA
MA
FL
UT
PA
GA
MD
TX
FL
UT
FL
NJ
NJ
AZ
AZ
CT
NJ
MD
CT
MA
MD
NJ
NJ
Rate Code 2953
(OOS Hospital
DRG)
Rate Code 2952
(OOS Hospital
Exempt)
Rate Code
Rate Code 2589 2950 and 2954
(DME Add-on)
(ALC RHCF)
Rate Code
2951 and 2955
(ALC Home
Care)
Rate Code 2990
(Capital per
Disch)
Rate Code 2991
(Capital per
Diem)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
5,812.44
8,982.32
8,982.32
6,489.00
5,812.44
5,812.44
5,812.44
8,982.32
5,812.44
6,489.00
5,812.44
5,812.44
6,489.00
5,812.44
8,982.32
5,812.44
5,812.44
5,812.44
5,812.44
5,812.44
6,489.00
5,812.44
5,812.44
5,812.44
5,812.44
5,812.44
5,812.44
5,812.44
7,446.80
6,489.00
5,812.44
5,812.44
5,812.44
8,982.32
5,812.44
5,812.44
5,812.44
5,812.44
6,489.00
6,489.00
8,982.32
8,982.32
8,982.32
7,446.80
6,489.00
8,982.32
8,982.32
5,812.44
5,812.44
7,446.80
6,489.00
6,489.00
-
4 of 10
1,395.82
1,395.82
463.71
1,395.82
463.71
463.71
1,395.82
463.71
463.71
1,395.82
463.71
463.71
1,395.82
1,395.82
1,395.82
463.71
1,395.82
1,395.82
463.71
463.71
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
187.52
254.96
254.96
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
254.96
254.96
254.96
254.96
187.52
254.96
254.96
187.52
187.52
254.96
187.52
187.52
187.52
254.96
254.96
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
254.96
254.96
254.96
254.96
187.52
254.96
254.96
187.52
187.52
254.96
187.52
187.52
617.64
760.34
760.34
617.64
617.64
617.64
617.64
760.34
617.64
617.64
617.64
617.64
617.64
617.64
760.34
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
760.34
617.64
617.64
617.64
617.64
760.34
617.64
617.64
617.64
617.64
617.64
617.64
760.34
760.34
760.34
760.34
617.64
760.34
760.34
617.64
617.64
760.34
617.64
617.64
129.64
154.04
154.04
129.64
129.64
129.64
129.64
154.04
129.64
129.64
129.64
129.64
129.64
129.64
154.04
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
129.64
129.64
129.64
129.64
154.04
129.64
129.64
129.64
129.64
129.64
129.64
154.04
154.04
154.04
154.04
129.64
154.04
154.04
129.64
129.64
154.04
129.64
129.64
WEF/ISAF
(for Cost
Outlier
Claims)
High Cost
Charge
Convertors
0.8386
1.0744
1.0744
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
1.0744
1.0744
1.0744
0.8386
1.0744
1.0744
0.8386
0.8386
1.0744
0.8386
0.8386
0.442464
0.357482
0.357482
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.357482
0.357482
0.357482
0.442464
0.357482
0.357482
0.442464
0.442464
0.357482
0.442464
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT-OF-STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/15 - 03/31/15
Hospital Name
KENNEDY MEM HOSP/WASHINGTON
KENT COUNTY MEMORIAL HOSPITAL
KESSLER INSTITUTE FOR REHAB
KINDRED HOSPITALS EAST LLC IL
KOSAIR CHILDRENS HSP KY
LAKE POINTE MEDICAL CENTER TX
LAKELAND REG MED CTR FL
LAKES REGION GEN HOSP-LACONIA
LAKEWOOD HOSP OH
LANCASTER GENERAL HOSP PA
LARGO MEDICAL CENTER FL
LAWRENCE & MEMORIAL HOSPS CT
LAWRENCE GEN HOSP MA
LDS HOSPITAL UT
LEESBURG REG MED CTR FL
LEHIGH VALLEY HOSP CTR PA
LEHIGH VALLEY MUHLENBERG PA
LENOIR MEMORIAL HOSP NC
LITTLETON REGIONAL HOSP NH
LOGAN REG HOSP UT
LOURDES MED CTR BURLINGTON CT
LOWELL GENERAL HOSPITAL MA
LUTHERAN HOSPITAL IN
LUTHERAN MEDICAL CENTER OH
LYNCHBURG GENERAL HOSP VA
MAGEE WOMENS HOSPITAL PA
MAIN LINE HOSP LANKENAU PA
MAINE MED CTR ME
MARTHAS VINEYARD HOSPITAL MA
MARY HITCHCOCK MEM HOSP NH
MARY WASHINGTON HOSPITAL VA
MARYMOUNT HOSPITAL OH
MASSACHUSETTS GEN HOSP
MAURY REGIONAL HSP TN
MCKEE MED CTR CO
MCLEOD LORIS SEACOAST HSP SC
MCLEOD MEDICAL CTR DILLON
MCLEOD REG MED CTR SC
MEDICAL CENTER AT PRINCETON
MEDICAL CENTER OF MC KINNEY T
MEDICAL CENTER OF PLANO TX
MEDICAL CITY DALLAS HOSP TX
MEDICAL CTR CENTRAL GEORGIA
MEDICAL CTR OF ARLINGTON TX
MEDICAL CTR OF OCEAN CO.
MEMORIAL HOSP PEMBROKE FL
MEMORIAL HOSPITAL FLAGER FL
MEMORIAL HOSPITAL IL
MEMORIAL HOSPITAL PA
MEMORIAL HOSPITAL PA
INC
MEMORIAL HOSPITAL RI
MEMORIAL HOSPITAL SOUTH BEND
City, State
TURNERSVILLE
WARWICK
WEST ORANGE
WILKES BARRE
LOUISVILLE
ROWLETT
LAKELAND
LACONIA
LAKEWOOD
LANCASTER
LARGO
NEW LONDON
LAWRENCE
SALT LAKE CITY
LEESBURG
ALLENTOWN
BETHLEHEM
KINSTON
LITTLETON
LOGAN
WILLINGBORO
LOWELL
FORT WAYNE
CLEVELAND
LYNCHBURG
PITTSBURGH
WYNNEWOOD
PORTLAND
OAK BLUFFS
LEBANON
FREDERICKSBURG
CLEVELAND
BOSTON
COLUMBIA
LOVELAND
LORIS
DILLON
FLORENCE
PRINCETON
MCKINNEY
PLANO
DALLAS
MACON
ARLINGTON
BRICK
PEMBROKE PINES
PALM COAST
BELLEVILLE
YORK
TOWANDA
PAWTUCKET
SOUTH BEND
NJ
RI
NJ
PA
KY
TX
FL
NH
OH
PA
FL
CT
MA
UT
FL
PA
PA
NC
NH
UT
NJ
MA
IN
OH
VA
PA
PA
ME
MA
NH
VA
OH
MA
TN
CO
SC
SC
SC
NJ
TX
TX
TX
GA
TX
NJ
FL
FL
IL
PA
PA
RI
IN
Rate Code 2953
(OOS Hospital
DRG)
Rate Code 2952
(OOS Hospital
Exempt)
Rate Code
Rate Code 2589 2950 and 2954
(DME Add-on)
(ALC RHCF)
Rate Code
2951 and 2955
(ALC Home
Care)
Rate Code 2990
(Capital per
Disch)
Rate Code 2991
(Capital per
Diem)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
6,489.00
5,812.44
7,446.80
5,812.44
7,446.80
5,812.44
5,812.44
5,812.44
5,812.44
6,489.00
5,812.44
6,489.00
6,489.00
5,812.44
5,812.44
6,489.00
6,489.00
5,812.44
5,812.44
5,812.44
6,489.00
5,812.44
6,489.00
6,489.00
5,812.44
6,489.00
5,812.44
6,489.00
5,812.44
6,489.00
5,812.44
5,812.44
8,982.32
5,812.44
5,812.44
5,812.44
5,812.44
6,489.00
5,812.44
5,812.44
5,812.44
8,982.32
5,812.44
5,812.44
5,812.44
5,812.44
5,812.44
5,812.44
6,489.00
5,812.44
6,489.00
6,489.00
-
5 of 10
463.71
463.71
463.71
463.71
463.71
463.71
463.71
463.71
463.71
463.71
463.71
463.71
1,395.82
463.71
1,395.82
463.71
463.71
463.71
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
187.52
187.52
254.96
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
617.64
617.64
760.34
617.64
760.34
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
760.34
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
760.34
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
129.64
129.64
154.04
129.64
154.04
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
WEF/ISAF
(for Cost
Outlier
Claims)
High Cost
Charge
Convertors
0.8386
0.8386
1.0744
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.442464
0.442464
0.357482
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT-OF-STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/15 - 03/31/15
Hospital Name
MEMORIAL HOSPITAL WEST FL
MEMORIAL REG HSP FL
MERCY MEDICAL CENTER MA
MERCY MEDICAL CENTER MD
MERIDIA EUCLID HSP OH
MERIDIA HILLCREST HSP OH
MERRIMACK VALLEY HSP A STEWRD
METHODIST CHARLTON MED CTR
METHODIST HLTHCRE OLIVE BR MS
METHODIST HOSP OF MEMPHIS TN
METHODIST HOSPITALS INC IN
METRO HEALTH SYSTEM OH
METRO WEST MEDICAL CENTER MA
METROPLEX HOSPITAL TX
MIAMI CHILDRENS HOSPITAL FL
MIDDLESEX HOSPITAL CT
MILFORD HOSPITAL CT
MILLCREEK COMMUNITY HOSPITAL
MILTON S HERSHEY MED CTR PA
MIRIAM HOSPITAL RI
MONTCLAIR HOSP/MOUNTAINSIDE
MONTCLAIR HOSP/MOUNTAINSIDE
MONTGOMERY GENERAL HOSP MD
MORRISTOWN MEMORIAL HOSP NJ
MOSES H CONE HOSPITAL NC
MOUNT SINAI MEDICAL CTR OF FL
MOUNTAIN VISTA MEDICAL CTR AZ
MT ASCUTNEY HOSPITAL VT
NASH GENERAL HOSPITAL NC
NEW MILFORD HSP
NEW PT RICHEY/MED CTR OF TRIN
NEWARK BETH ISRAEL MED NJ
NEWPORT HSP RI
NEWTON WELLESLEY HOSP MA
NORTH BROWARD MEDICAL CTR FL
NORTH COUNTRY HOSPITAL VT
NORTH HILLS HOSPITAL TX
NORTH PHILADELPHIA HLTH SYS
NORTH SHORE MED CTR FL
NORTHEAST ALABAMA REG MED
NORTHERN COCHISE COMM HSP AZ
NORTHERN UTAH HEALTHCARE UT
NORTHSHORE UNIVERSITY HEALTH
NORTHWEST TEXAS HOSPITAL
NORWALK HOSPITAL
NORWOOD HOSP INC MA
ORLANDO REG HLTH SYS FL
OU MEDICAL CENTER OK
OUR LADY OF LOURDES MED CTR N
OVERLOOK HOSPITAL NJ
PALISADES MEDICAL CENTER NJ
PALM BAY HOSPITAL FL
City, State
PEMBROKE PINES
HOLLYWOOD
SPRINGFIELD
BALTIMORE
EUCLID
MAYFIELD HTS
HAVERHILL
DALLAS
OLIVE BRANCH
MEMPHIS
GARY
CLEVELAND
FRAMINGHAM
KILLEEN
MIAMI
MIDDLETOWN
MILFORD
ERIE
HERSHEY
PROVIDENCE
MONTCLAIR
MONTCLAIR
OLNEY
MORRISTOWN
GREENSBORO
MIAMI BEACH
MESA
WINDSOR
ROCKY MOUNT
NEW MILFORD
TRINITY
NEWARK
NEWPORT
NEWTON
POMPANO BEACH
NEWPORT
NORTH RICHLAND HILLS
PHILADELPHIA
MIAMI
ANNISTON
WILLCOX
SALT LAKE CITY
EVANSTON
AMARILLO
NORWALK
NORWOOD
ORLANDO
OKLAHOMA CITY
CAMDEN
SUMMIT
NORTH BERGEN
PALM BAY
FL
FL
MA
MD
OH
OH
MA
TX
MS
TN
IN
OH
MA
TX
FL
CT
CT
PA
PA
RI
NJ
NJ
MD
NJ
NC
FL
AZ
VT
NC
CT
FL
NJ
RI
MA
FL
VT
TX
PA
FL
AL
AZ
UT
IL
TX
CT
MA
FL
OK
NJ
NJ
NJ
FL
Rate Code 2953
(OOS Hospital
DRG)
Rate Code 2952
(OOS Hospital
Exempt)
Rate Code
Rate Code 2589 2950 and 2954
(DME Add-on)
(ALC RHCF)
Rate Code
2951 and 2955
(ALC Home
Care)
Rate Code 2990
(Capital per
Disch)
Rate Code 2991
(Capital per
Diem)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
5,812.44
6,489.00
5,812.44
8,982.32
5,812.44
5,812.44
5,812.44
8,982.32
5,812.44
8,982.32
6,489.00
6,489.00
5,812.44
5,812.44
6,489.00
6,489.00
5,812.44
6,489.00
6,489.00
6,489.00
8,982.32
8,982.32
5,812.44
6,489.00
6,489.00
6,489.00
5,812.44
5,812.44
5,812.44
7,446.80
5,812.44
8,982.32
5,812.44
6,489.00
5,812.44
5,812.44
5,812.44
7,446.80
5,812.44
6,489.00
5,812.44
6,489.00
5,812.44
6,489.00
8,982.32
5,812.44
6,489.00
8,982.32
6,489.00
8,982.32
7,446.80
5,812.44
-
6 of 10
463.71
1,395.82
1,395.82
1,395.82
463.71
463.71
463.71
463.71
463.71
463.71
463.71
1,395.82
1,395.82
463.71
463.71
463.71
1,395.82
463.71
463.71
463.71
463.71
1,395.82
463.71
1,395.82
463.71
1,395.82
-
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
187.52
187.52
187.52
254.96
187.52
187.52
187.52
254.96
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
254.96
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
254.96
187.52
254.96
254.96
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
254.96
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
254.96
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
254.96
187.52
254.96
254.96
187.52
617.64
617.64
617.64
760.34
617.64
617.64
617.64
760.34
617.64
760.34
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
760.34
760.34
617.64
617.64
617.64
617.64
617.64
617.64
617.64
760.34
617.64
760.34
617.64
617.64
617.64
617.64
617.64
760.34
617.64
617.64
617.64
617.64
617.64
617.64
760.34
617.64
617.64
760.34
617.64
760.34
760.34
617.64
129.64
129.64
129.64
154.04
129.64
129.64
129.64
154.04
129.64
154.04
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
154.04
129.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
129.64
154.04
129.64
129.64
129.64
129.64
129.64
154.04
129.64
129.64
129.64
129.64
129.64
129.64
154.04
129.64
129.64
154.04
129.64
154.04
154.04
129.64
WEF/ISAF
(for Cost
Outlier
Claims)
High Cost
Charge
Convertors
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
1.0744
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
1.0744
0.8386
1.0744
1.0744
0.8386
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.357482
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.357482
0.442464
0.357482
0.357482
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT-OF-STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/15 - 03/31/15
Hospital Name
PALM BEACH GARDENS AND MED CT
PALMERTON HOSPITAL PA
PAOLI MEMORIAL HOSPITAL
PARKLAND MEM HOSP TX
PARKVIEW HOSPITAL INC IN
PASCACK VALLEY HOSP LLC NJ
PENNSYLVANIA HOSP PA
PENOBSCOT BAY MED CTR ME
PHOENIX CHILDRENS HSP AZ
PINNACLE HEALTH HOSPITALS PA
PITT COUNTY MEMORIAL HOSP NC
POCONO MED CTR PA
PORTER MEDICAL CENTER INC VT
PORTER MEDICAL CENTER INC VT
POTOMAC HSP OF PRINCE WILL VA
POTOMAC VALLEY HSP OF WEST VA
POTTSTOWN MEM MED CTR PA
PRESBYTERIAN HOSP NM
PRESBYTERIAN HSP OF DALLAS
PRESBYTERIAN INTERCOMM HSP CA
PRESBYTERIAN UNIV HSP PA
PRESBYTERIAN UNIV HSP PA
PRESBYTERIAN UNIV HSP PA
PRESBYTERIAN UNIV HSP PA
PRESBYTERIAN UNIV HSP PA
PRIMARY CHILDRENS MED CTR UT
PROVIDENCE ST PETERS HOSP WA
QUINCY MED CTR A STEWARD FAM
QUINCY MED CTR A STEWARD FAM
RARITAN BAY HEALTH SERVICES
REFUGIO COUNTY MEM HSP TX
REG CTR ORANGEBURG CALHOUN SC
REGIONAL HSP SCRANTON PA
REGIONAL MED CTR AT MEMPHIS
REGIONAL MED CTR BAYONET FL
RESEARCH MED CTR MO
RHODE ISLAND HOSPITAL RI
RIDDLE MEMORIAL HOSP PA
RIVERTON HOSPITAL UT
RIVERVIEW HOSPITAL NJ
ROBERT PACKER HOSP PA
ROBERT WOOD JOHNSON UNIV HSP
ROGUE VALLEY MEMORIAL HSP OR
ROSWELL HOSPITAL CORP NM
RUSH UNIVERSITY MED CTR IL
RUSH UNIVERSITY MED CTR IL
RUSH UNIVERSITY MED CTR IL
RUTLAND REG MED CTR
SACRED HEART HOSPITAL PA
SACRED HEART MED CTR UNIV DIS
SAINT BARNABAS MEDICAL CENTER
SAINT VINCENTS HLTH CTR
City, State
PALM BEACH GARDENS
PALMERTON
PAOLI
DALLAS
FORT WAYNE
WESTWOOD
PHILADELPHIA
ROCKPORT
PHOENIX
HARRISBURG
GREENVILLE
E STROUDSBURG
MIDDLEBURY
MIDDLEBURY
WOODBRIDGE
KEYSER
POTTSTOWN
ALBUQUERQUE
DALLAS
WHITTIER
PITTSBURGH
PITTSBURGH
PITTSBURGH
PITTSBURGH
PITTSBURGH
SALT LAKE CITY
OLYMPIA
QUINCY
QUINCY
PERTH AMBOY
REFUGIO
ORANGEBURG
SCRANTON
MEMPHIS
HUDSON
KANSAS CITY
PROVIDENCE
MEDIA
RIVERTON
RED BANK
SAYRE
NEW BRUNSWICK
MEDFORD
ROSWELL
CHICAGO
CHICAGO
CHICAGO
RUTLAND
ALLENTOWN
EUGENE
OCEAN PORT
ERIE
FL
PA
PA
TX
IN
NJ
PA
ME
AZ
PA
NC
PA
VT
VT
VA
WV
PA
NM
TX
CA
PA
PA
PA
PA
PA
UT
WA
MA
MA
NJ
TX
SC
PA
TN
FL
MO
RI
PA
UT
NJ
PA
NJ
OR
NM
IL
IL
IL
VT
PA
OR
NJ
PA
Rate Code 2953
(OOS Hospital
DRG)
Rate Code 2952
(OOS Hospital
Exempt)
Rate Code
Rate Code 2589 2950 and 2954
(DME Add-on)
(ALC RHCF)
Rate Code
2951 and 2955
(ALC Home
Care)
Rate Code 2990
(Capital per
Disch)
Rate Code 2991
(Capital per
Diem)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
5,812.44
5,812.44
5,812.44
8,982.32
6,489.00
8,982.32
8,982.32
5,812.44
7,446.80
6,489.00
6,489.00
5,812.44
5,812.44
5,812.44
5,812.44
5,812.44
5,812.44
8,982.32
8,982.32
6,489.00
6,489.00
6,489.00
6,489.00
6,489.00
6,489.00
6,489.00
6,489.00
5,812.44
5,812.44
8,982.32
5,812.44
5,812.44
6,489.00
8,982.32
5,812.44
6,489.00
6,489.00
5,812.44
5,812.44
7,446.80
6,489.00
8,982.32
5,812.44
5,812.44
8,982.32
8,982.32
8,982.32
5,812.44
6,489.00
5,812.44
6,489.00
6,489.00
-
7 of 10
1,395.82
463.71
1,395.82
1,395.82
463.71
463.71
1,395.82
1,395.82
463.71
463.71
463.71
463.71
463.71
463.71
463.71
463.71
1,395.82
463.71
1,395.82
463.71
463.71
463.71
1,395.82
1,395.82
1,395.82
1,395.82
463.71
463.71
463.71
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
187.52
187.52
187.52
254.96
187.52
254.96
254.96
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
254.96
187.52
254.96
187.52
187.52
254.96
254.96
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
254.96
254.96
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
254.96
187.52
254.96
187.52
187.52
254.96
254.96
254.96
187.52
187.52
187.52
187.52
187.52
617.64
617.64
617.64
760.34
617.64
760.34
760.34
617.64
760.34
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
760.34
760.34
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
760.34
617.64
617.64
617.64
760.34
617.64
617.64
617.64
617.64
617.64
760.34
617.64
760.34
617.64
617.64
760.34
760.34
760.34
617.64
617.64
617.64
617.64
617.64
129.64
129.64
129.64
154.04
129.64
154.04
154.04
129.64
154.04
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
154.04
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
129.64
129.64
129.64
154.04
129.64
129.64
129.64
129.64
129.64
154.04
129.64
154.04
129.64
129.64
154.04
154.04
154.04
129.64
129.64
129.64
129.64
129.64
WEF/ISAF
(for Cost
Outlier
Claims)
High Cost
Charge
Convertors
0.8386
0.8386
0.8386
1.0744
0.8386
1.0744
1.0744
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
1.0744
0.8386
0.8386
1.0744
1.0744
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.442464
0.442464
0.442464
0.357482
0.442464
0.357482
0.357482
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.357482
0.442464
0.442464
0.357482
0.357482
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT-OF-STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/15 - 03/31/15
Hospital Name
SAINTS MEM MED CTR MA
SALINA REG HLTH CTR KS
SAN ANTONIO COMM HSP CA
SARASOTA MEMORIAL HOSPITAL FL
SCHUYLKILL MED CTR SOUTH PA
SCOTTSDALE HLTHCARE SHEA AZ
SELECT SPEC HOSP DANVILLE
SELECT SPEC HOSP ERIE
SELECT SPEC HOSP NORTHEAST NJ
SENTARA BAYSIDE HOSP VA
SENTARA CAREPLEX HOSPITAL VA
SENTARA HOSPITAL VA
SENTARA LEIGH HSP VA
SENTARA NORFOLK HSP VA
SENTARA VIRGINIA BEACH GEN HS
SENTARA WILLIAMSBURG COMM HOS
SEVIER VALLEY MEDICAL CTR UT
SHANDS JACKSONVILLE MED FL
SHARON HOSPITAL CT
SHARP CHULA VISTA
SOLDIERS AND SAILORS MEM HOSP
SOMERSET MED CENTER NJ
SOUTH BAY HOSP FL
SOUTH COUNTY HOSPTAL RI
SOUTH LAKE HSP FL
SOUTH MIAMI HOSPITAL FL
SOUTH POINTE HOSPITAL OH
SOUTH SHORE HOSP MA
SOUTHEASTERN REG MED CTR NC
SOUTHERN HILLS M C TN
SOUTHERN MARYLAND HOSP INC
SOUTHERN OCEAN MED CTR NJ
SOUTHSIDE COMM HOSP VA
SOUTHWEST GENERAL HOSPITAL
SOUTHWESTERN VT MED CTR INC
SPEARE MEMORIAL HOSP NH
SPECIALTY HOSP OF CLEVELAND
SPRING VALLEY HOSP MED NV
SPRING VALLEY HOSP MED NV
ST CHRISTOPHERS HSP CHILD PA
ST CLARE HOSPITAL WI
ST CLARES HOSPITAL
ST FRANCIS HOSP & MED CTR CT
ST FRANCIS HOSPITAL OK
ST FRANCIS HSP DE
ST JOSEPH HOSPITAL PA
ST JOSEPHS HOSP MED CTR NJ
ST JUDE CHILDRENS RES HSP TN
ST LOUIS CHILDRENS HOSP MO
ST LUKES HOSPITAL
ST LUKES HOSPITAL
ST LUKES HOSPITAL MA
City, State
LOWELL
SALINA
UPLAND
SARASOTA
POTTSVILLE
SCOTTSDALE
DANVILLE
ERIE
ROCHELLE PARK
VIRGINIA BEACH
HAMPTON
SUFFOLK
NORFOLK
NORFOLK
VIRGINIA BEACH
WILLIAMSBURG
RICHFIELD
JACKSONVILLE
SHARON
CHULA VISTA
WELLSBORO
SOMERVILLE
SUN CITY CENTER
WAKEFIELD
CLERMONT
SOUTH MIAMI
WARRENSVILLE HTS
SOUTH WEYMOUTH
LUMBERTON
NASHVILLE
CLINTON
MANAHAWKIN
FARMVILLE
CLEVELAND
BENNINGTON
PLYMOUTH
CLEVELAND
LAS VEGAS
LAS VEGAS
PHILADELPHIA
BARABOO
DENVILLE
HARTFORD
TULSA
WILMINGTON
READING
PATERSON
MEMPHIS
SAINT LOUIS
BETHLEHEM
MILWAUKEE
FALL RIVER
MA
KS
CA
FL
PA
AZ
PA
PA
NJ
VA
VA
VA
VA
VA
VA
VA
UT
FL
CT
CA
PA
NJ
FL
RI
FL
FL
OH
MA
NC
TN
MD
NJ
VA
OH
VT
NH
OH
NV
NV
PA
WI
NJ
CT
OK
DE
PA
NJ
TN
MO
PA
WI
MA
Rate Code 2953
(OOS Hospital
DRG)
Rate Code 2952
(OOS Hospital
Exempt)
Rate Code
Rate Code 2589 2950 and 2954
(DME Add-on)
(ALC RHCF)
Rate Code
2951 and 2955
(ALC Home
Care)
Rate Code 2990
(Capital per
Disch)
Rate Code 2991
(Capital per
Diem)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
5,812.44
6,489.00
5,812.44
5,812.44
5,812.44
6,489.00
6,489.00
5,812.44
7,446.80
6,489.00
5,812.44
6,489.00
6,489.00
6,489.00
6,489.00
5,812.44
5,812.44
8,982.32
7,446.80
5,812.44
5,812.44
6,489.00
5,812.44
5,812.44
5,812.44
6,489.00
6,489.00
5,812.44
5,812.44
7,446.80
5,812.44
5,812.44
5,812.44
5,812.44
5,812.44
5,812.44
5,812.44
8,982.32
8,982.32
7,446.80
6,489.00
5,812.44
6,489.00
5,812.44
6,489.00
6,489.00
8,982.32
7,446.80
5,812.44
6,489.00
7,446.80
5,812.44
-
8 of 10
463.71
463.71
463.71
463.71
463.71
463.71
463.71
463.71
1,395.82
463.71
463.71
463.71
1,395.82
1,395.82
463.71
463.71
463.71
463.71
1,395.82
463.71
-
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
254.96
254.96
187.52
187.52
187.52
187.52
187.52
187.52
254.96
254.96
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
254.96
254.96
187.52
187.52
187.52
187.52
187.52
187.52
254.96
254.96
187.52
187.52
254.96
187.52
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
760.34
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
760.34
760.34
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
760.34
617.64
617.64
617.64
617.64
617.64
617.64
617.64
760.34
760.34
760.34
617.64
617.64
617.64
617.64
617.64
617.64
760.34
760.34
617.64
617.64
760.34
617.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
154.04
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
129.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
154.04
154.04
129.64
129.64
129.64
129.64
129.64
129.64
154.04
154.04
129.64
129.64
154.04
129.64
WEF/ISAF
(for Cost
Outlier
Claims)
High Cost
Charge
Convertors
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
1.0744
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
1.0744
0.8386
0.8386
1.0744
0.8386
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.357482
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.357482
0.442464
0.442464
0.357482
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT-OF-STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/15 - 03/31/15
Hospital Name
ST LUKES HSP OF KC MO
ST LUKES NORTHLAND HSP MO
ST MARY HOSPITAL PA
ST MARY MERCY HSP MI
ST MARYS HOSP AND MED CTR
ST MARYS HOSPITAL OF CONN
ST MARYS REG MED CENTER ME
ST MICHAEL MED CENTER NJ
ST PETERS UNIV HSP NJ
ST VINCENT HOSPITAL MA
ST VINCENTS MEDICAL CENTER CT
STAFFORD HOSPITAL VA
STAMFORD HOSPITAL CT
STEWARD CARNEY HOSP INC
STEWARD CARNEY HOSP MA
STEWARD GOOD SAM MED CTR MA
STEWARD GOOD SAM MED CTR MA
STEWARD HOLY FAMILY MA
STEWARD NORWOOD HOSP MA
STEWARD ST ANNES HSP MA
STEWARD ST ELIZABETH MED CTR
STORMONT VAIL REG MED CTR KS
STURDY MEMORIAL HOSP MA
SUMMERLIN MED CTR NV
SUNRISE HOSP & MED CTR NV
SWEETWATER HOSP TN
TEMPLE UNIVERSITY HOSPITAL
TEXAS CHILDREN'S HOSP TX
TEXAS HLTH PRESBYTERIAN HOSP
THE MERCY HOSP/PROVIDENCE
THE SHRINERS HOSP FOR CHILD MA
THE SHRINERS HOSP FOR CHILD MA
THOMAS JEFFERSON UNIV HOSP PA
THREE RIVERS COMMUNITY HSP OR
TOLEDO HSP OH
TRINITAS HSP NJ
TROY COMMUNITY HOSPITAL
TUFTS MEDICAL CENTER MA
TUOMEY REG MED CTR SC
UMASS MEMORIAL MED CNTR PSYCH
UMASS MEMORIAL MEDICAL CENTER
UNION HOSP OF CECIL CTY MD
UNITED HOSPITAL MN
UNIV CA DAVIS MED CTR CA
UNIV KENTUCKY HOSPITAL
UNIV OF ALABAMA
UNIV OF WASHINGTON WA
UNIVERSITY COMM HOSP FL
UNIVERSITY OF KANSAS HOSPITAL
UNIVERSITY OF TENNESSEE MEM
UPHS PRESBYTERIAN MEDICAL CEN
UPPER CHESAPEAK MEDICAL CENTE
City, State
KANSAS CITY
SMITHVILLE
LANGHORNE
LIVONIA
GRAND JUNCTION
WATERBURY
LEWISTON
NEWARK
NEW BRUNSWICK
WORCESTER
BRIDGEPORT
STAFFORD
STAMFORD
DORCHESTER
DORCHESTER
BROCKTON
BROCKTON
METHUEN
NORWOOD
FALL RIVER
BOSTON
TOPEKA
ATTLEBORO
LAS VEGAS
LAS VEGAS
SWEETWATER
PHILADELPHIA
HOUSTON
ALLEN
HOLYOKE
BOSTON
SPRINGFIELD
PHILADELPHIA
GRANTS PASS
TOLEDO
ELIZABETH
TROY
WORCESTER
SUMTER
WORCESTER
WORCESTER
ELKTON
SAINT PAUL
SACRAMENTO
LEXINGTON
BIRMINGHAM
SEATTLE
TAMPA
KANSAS CITY
KNOXVILLE
PHILADELPHIA
BEL AIR
MO
MO
PA
MI
CO
CT
ME
NJ
NJ
MA
CT
VA
CT
MA
MA
MA
MA
MA
MA
MA
MA
KS
MA
NV
NV
TN
PA
TX
TX
MA
MA
MA
PA
OR
OH
NJ
PA
MA
SC
MA
MA
MD
MN
CA
KY
AL
WA
FL
KS
TN
PA
MD
Rate Code 2953
(OOS Hospital
DRG)
Rate Code 2952
(OOS Hospital
Exempt)
Rate Code
Rate Code 2589 2950 and 2954
(DME Add-on)
(ALC RHCF)
Rate Code
2951 and 2955
(ALC Home
Care)
Rate Code 2990
(Capital per
Disch)
Rate Code 2991
(Capital per
Diem)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
6,489.00
5,812.44
5,812.44
5,812.44
6,489.00
6,489.00
5,812.44
8,982.32
7,446.80
6,489.00
8,982.32
5,812.44
8,982.32
6,489.00
6,489.00
6,489.00
6,489.00
5,812.44
5,812.44
6,489.00
8,982.32
6,489.00
5,812.44
7,446.80
8,982.32
5,812.44
8,982.32
7,446.80
5,812.44
5,812.44
7,446.80
5,812.44
8,982.32
5,812.44
6,489.00
8,982.32
5,812.44
6,489.00
5,812.44
5,812.44
6,489.00
5,812.44
6,489.00
6,489.00
6,489.00
5,812.44
8,982.32
5,812.44
6,489.00
6,489.00
7,446.80
5,812.44
-
9 of 10
463.71
463.71
463.71
1,395.82
463.71
1,395.82
1,395.82
463.71
463.71
463.71
463.71
463.71
1,395.82
463.71
1,395.82
1,395.82
1,395.82
463.71
1,395.82
463.71
463.71
463.71
463.71
463.71
1,395.82
463.71
463.71
-
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
254.96
187.52
254.96
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
254.96
254.96
187.52
254.96
254.96
187.52
187.52
254.96
187.52
254.96
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
254.96
187.52
254.96
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
254.96
254.96
187.52
254.96
254.96
187.52
187.52
254.96
187.52
254.96
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
254.96
187.52
617.64
617.64
617.64
617.64
617.64
617.64
617.64
760.34
760.34
617.64
760.34
617.64
760.34
617.64
617.64
617.64
617.64
617.64
617.64
617.64
760.34
617.64
617.64
760.34
760.34
617.64
760.34
760.34
617.64
617.64
760.34
617.64
760.34
617.64
617.64
760.34
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
760.34
617.64
617.64
617.64
760.34
617.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
154.04
129.64
154.04
129.64
154.04
129.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
129.64
129.64
154.04
154.04
129.64
154.04
154.04
129.64
129.64
154.04
129.64
154.04
129.64
129.64
154.04
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
154.04
129.64
129.64
129.64
154.04
129.64
WEF/ISAF
(for Cost
Outlier
Claims)
High Cost
Charge
Convertors
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
1.0744
0.8386
1.0744
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
1.0744
1.0744
0.8386
1.0744
1.0744
0.8386
0.8386
1.0744
0.8386
1.0744
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
1.0744
0.8386
0.8386
0.8386
1.0744
0.8386
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.357482
0.442464
0.357482
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.357482
0.357482
0.442464
0.357482
0.357482
0.442464
0.442464
0.357482
0.442464
0.357482
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.357482
0.442464
0.442464
0.442464
0.357482
0.442464
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT-OF-STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/15 - 03/31/15
Hospital Name
UT VALLEY REG MED CTR UT
VALLEY HOSPITAL
VALLEY VIEW HOSP ASSOC CO
VERDE VALLEY MED CTR AZ
VIBRA HOSP OF WESTERN MASS
VIDANT BEAUFORT HOSP
VILLAGES REGIONAL HOSP FL
VIRGINIA BEACH PSYCHIATRIC
WARREN GENERAL HOSPITAL PA
WARSAW HLTH/KOSCIUSKO COMM
WATERBURY HOSPITAL CT
WAYNE MEMORIAL HOSP PA
WELLSTAR DOUGLAS HOSP GA
WELLSTAR KENNESTONE HOSP GA
WEST GROVE/JENNERSVILLE PA
WEST KENDALL BAPTIST HOSP FL
WEST VIRGINA UNIV HOSP WV
WICKENBURG COMM HOSP AZ
WILLIAM BACKUS HOSPITAL CT
WILLIAM BEAUMONT HOSP
WING MEMORIAL HOSPITAL MA
WOMEN & INFANTS HSP RI
WVHCS HOSP WILKES BARRE PA
YALE NEW HAVEN HOSPITAL CT
YORK HOSPITAL
YORK HOSPITAL ME
City, State
PROVO
RIDGEWOOD
GLENWOOD SPRINGS
COTTONWOOD
SPRINGFIELD
GREENVILLE
THE VILLAGES
VIRGINIA BEACH
WARREN
WARSAW
WATERBURY
HONESDALE
DOUGLASVILLE
MARIETTA
WEST GROVE
MIAMI
MORGANTOWN
WICKENBURG
NORWICH
ROYAL OAK
PALMER
PROVIDENCE
WILKES BARRE
NEW HAVEN
YORK
YORK
UT
NJ
CO
AZ
MA
NC
FL
VA
PA
IN
CT
PA
GA
GA
PA
FL
WV
AZ
CT
MI
MA
RI
PA
CT
PA
ME
Rate Code 2953
(OOS Hospital
DRG)
Rate Code 2952
(OOS Hospital
Exempt)
Rate Code
Rate Code 2589 2950 and 2954
(DME Add-on)
(ALC RHCF)
Rate Code
2951 and 2955
(ALC Home
Care)
Rate Code 2990
(Capital per
Disch)
Rate Code 2991
(Capital per
Diem)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
6,489.00
7,446.80
5,812.44
5,812.44
5,812.44
5,812.44
5,812.44
5,812.44
5,812.44
5,812.44
6,489.00
5,812.44
5,812.44
5,812.44
5,812.44
5,812.44
6,489.00
5,812.44
5,812.44
6,489.00
5,812.44
6,489.00
6,489.00
6,489.00
6,489.00
5,812.44
-
10 of 10
463.71
463.71
463.71
463.71
463.71
463.71
463.71
463.71
-
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
254.96
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
187.52
617.64
760.34
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
617.64
129.64
154.04
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
129.64
WEF/ISAF
(for Cost
Outlier
Claims)
High Cost
Charge
Convertors
0.8386
1.0744
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.8386
0.442464
0.357482
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464
0.442464