|
OUTPATIENT EAPG 00327: INTENSIVE OUTPATIENT PSYCHIATRIC TREATMENT
|
Facility
|
OP
|
$291.04
|
|
|
Service Code
|
EAPG 00327
|
| Hospital Charge Code |
EAPG 00327
|
| Min. Negotiated Rate |
$128.18 |
| Max. Negotiated Rate |
$291.04 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$288.40
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$288.40
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$128.18
|
| Rate for Payer: Amida Care Medicaid |
$128.18
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$129.35
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$128.18
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$288.40
|
| Rate for Payer: Fidelis Essential Plan QHP |
$288.40
|
| Rate for Payer: Fidelis Qualified Health Plan |
$134.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$128.18
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$128.18
|
| Rate for Payer: Healthfirst Commercial |
$194.25
|
| Rate for Payer: Healthfirst Essential Plan |
$288.40
|
| Rate for Payer: Healthfirst QHP |
$128.18
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$129.35
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$291.04
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$291.04
|
| Rate for Payer: Optum Medicaid |
$129.35
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$128.18
|
| Rate for Payer: SOMOS Essential |
$288.40
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$288.40
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$141.00
|
| Rate for Payer: United Healthcare Medicaid |
$128.18
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$128.18
|
|
|
OUTPATIENT EAPG 00328: DAY REHABILITATION, HALF DAY
|
Facility
|
OP
|
$235.84
|
|
|
Service Code
|
EAPG 00328
|
| Hospital Charge Code |
EAPG 00328
|
| Min. Negotiated Rate |
$103.87 |
| Max. Negotiated Rate |
$235.84 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$233.71
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$233.71
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$103.87
|
| Rate for Payer: Amida Care Medicaid |
$103.87
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$104.82
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$103.87
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$233.71
|
| Rate for Payer: Fidelis Essential Plan QHP |
$233.71
|
| Rate for Payer: Fidelis Qualified Health Plan |
$109.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$103.87
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$103.87
|
| Rate for Payer: Healthfirst Commercial |
$157.39
|
| Rate for Payer: Healthfirst Essential Plan |
$233.71
|
| Rate for Payer: Healthfirst QHP |
$103.87
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$104.82
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$235.84
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$235.84
|
| Rate for Payer: Optum Medicaid |
$104.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$103.87
|
| Rate for Payer: SOMOS Essential |
$233.71
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$233.71
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$114.26
|
| Rate for Payer: United Healthcare Medicaid |
$103.87
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$103.87
|
|
|
OUTPATIENT EAPG 00329: DAY REHABILITATION, FULL DAY
|
Facility
|
OP
|
$314.46
|
|
|
Service Code
|
EAPG 00329
|
| Hospital Charge Code |
EAPG 00329
|
| Min. Negotiated Rate |
$138.50 |
| Max. Negotiated Rate |
$314.46 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$311.62
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$311.62
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$138.50
|
| Rate for Payer: Amida Care Medicaid |
$138.50
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$139.76
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$138.50
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$311.62
|
| Rate for Payer: Fidelis Essential Plan QHP |
$311.62
|
| Rate for Payer: Fidelis Qualified Health Plan |
$145.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$138.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$138.50
|
| Rate for Payer: Healthfirst Commercial |
$209.88
|
| Rate for Payer: Healthfirst Essential Plan |
$311.62
|
| Rate for Payer: Healthfirst QHP |
$138.50
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$139.76
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$314.46
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$314.46
|
| Rate for Payer: Optum Medicaid |
$139.76
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$138.50
|
| Rate for Payer: SOMOS Essential |
$311.62
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$311.62
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$152.35
|
| Rate for Payer: United Healthcare Medicaid |
$138.50
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$138.50
|
|
|
OUTPATIENT EAPG 00331: LEVEL I DIAGNOSTIC NUCLEAR MEDICINE
|
Facility
|
OP
|
$882.74
|
|
|
Service Code
|
EAPG 00331
|
| Hospital Charge Code |
EAPG 00331
|
| Min. Negotiated Rate |
$392.33 |
| Max. Negotiated Rate |
$882.74 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$882.74
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$882.74
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$392.33
|
| Rate for Payer: Amida Care Medicaid |
$392.33
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$392.33
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$882.74
|
| Rate for Payer: Fidelis Essential Plan QHP |
$882.74
|
| Rate for Payer: Fidelis Qualified Health Plan |
$411.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$392.33
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$392.33
|
| Rate for Payer: Healthfirst Commercial |
$594.51
|
| Rate for Payer: Healthfirst Essential Plan |
$882.74
|
| Rate for Payer: Healthfirst QHP |
$392.33
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$392.33
|
| Rate for Payer: SOMOS Essential |
$882.74
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$882.74
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$431.56
|
| Rate for Payer: United Healthcare Medicaid |
$392.33
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$392.33
|
|
|
OUTPATIENT EAPG 00332: LEVEL II DIAGNOSTIC NUCLEAR MEDICINE
|
Facility
|
OP
|
$1,926.50
|
|
|
Service Code
|
EAPG 00332
|
| Hospital Charge Code |
EAPG 00332
|
| Min. Negotiated Rate |
$856.22 |
| Max. Negotiated Rate |
$1,926.50 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,926.50
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,926.50
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$856.22
|
| Rate for Payer: Amida Care Medicaid |
$856.22
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$856.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,926.50
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,926.50
|
| Rate for Payer: Fidelis Qualified Health Plan |
$899.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$856.22
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$856.22
|
| Rate for Payer: Healthfirst Commercial |
$1,297.45
|
| Rate for Payer: Healthfirst Essential Plan |
$1,926.50
|
| Rate for Payer: Healthfirst QHP |
$856.22
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$856.22
|
| Rate for Payer: SOMOS Essential |
$1,926.50
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$1,926.50
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$941.84
|
| Rate for Payer: United Healthcare Medicaid |
$856.22
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$856.22
|
|
|
OUTPATIENT EAPG 00333: BEHAVIORAL HEALTH RESIDENTIAL TREATMENT
|
Facility
|
OP
|
$314.46
|
|
|
Service Code
|
EAPG 00333
|
| Hospital Charge Code |
EAPG 00333
|
| Min. Negotiated Rate |
$138.50 |
| Max. Negotiated Rate |
$314.46 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$311.62
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$311.62
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$138.50
|
| Rate for Payer: Amida Care Medicaid |
$138.50
|
| Rate for Payer: Carelon Behavioral Health HARP/QHP |
$139.76
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$138.50
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$311.62
|
| Rate for Payer: Fidelis Essential Plan QHP |
$311.62
|
| Rate for Payer: Fidelis Qualified Health Plan |
$145.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$138.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$138.50
|
| Rate for Payer: Healthfirst Essential Plan |
$311.62
|
| Rate for Payer: Healthfirst QHP |
$138.50
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$139.76
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$314.46
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$314.46
|
| Rate for Payer: Optum Medicaid |
$139.76
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$138.50
|
| Rate for Payer: SOMOS Essential |
$311.62
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$311.62
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$152.35
|
| Rate for Payer: United Healthcare Medicaid |
$138.50
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$138.50
|
|
|
OUTPATIENT EAPG 00335: LEVEL I BRACHYTHERAPY SOURCES
|
Facility
|
OP
|
$2,546.39
|
|
|
Service Code
|
EAPG 00335
|
| Hospital Charge Code |
EAPG 00335
|
| Min. Negotiated Rate |
$1,131.73 |
| Max. Negotiated Rate |
$2,546.39 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,546.39
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,546.39
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,131.73
|
| Rate for Payer: Amida Care Medicaid |
$1,131.73
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,131.73
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$2,546.39
|
| Rate for Payer: Fidelis Essential Plan QHP |
$2,546.39
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,188.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,131.73
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,131.73
|
| Rate for Payer: Healthfirst Essential Plan |
$2,546.39
|
| Rate for Payer: Healthfirst QHP |
$1,131.73
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,131.73
|
| Rate for Payer: SOMOS Essential |
$2,546.39
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$2,546.39
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$1,244.90
|
| Rate for Payer: United Healthcare Medicaid |
$1,131.73
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,131.73
|
|
|
OUTPATIENT EAPG 00336: LEVEL II BRACHYTHERAPY SOURCES
|
Facility
|
OP
|
$3,564.97
|
|
|
Service Code
|
EAPG 00336
|
| Hospital Charge Code |
EAPG 00336
|
| Min. Negotiated Rate |
$1,584.43 |
| Max. Negotiated Rate |
$3,564.97 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$3,564.97
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3,564.97
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,584.43
|
| Rate for Payer: Amida Care Medicaid |
$1,584.43
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,584.43
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,564.97
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,564.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,663.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,584.43
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$1,584.43
|
| Rate for Payer: Healthfirst Essential Plan |
$3,564.97
|
| Rate for Payer: Healthfirst QHP |
$1,584.43
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,584.43
|
| Rate for Payer: SOMOS Essential |
$3,564.97
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$3,564.97
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$1,742.87
|
| Rate for Payer: United Healthcare Medicaid |
$1,584.43
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,584.43
|
|
|
OUTPATIENT EAPG 00337: LEVEL III BRACHYTHERAPY SOURCES
|
Facility
|
OP
|
$37,158.82
|
|
|
Service Code
|
EAPG 00337
|
| Hospital Charge Code |
EAPG 00337
|
| Min. Negotiated Rate |
$16,515.03 |
| Max. Negotiated Rate |
$37,158.82 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$37,158.82
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$37,158.82
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$16,515.03
|
| Rate for Payer: Amida Care Medicaid |
$16,515.03
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16,515.03
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$37,158.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$37,158.82
|
| Rate for Payer: Fidelis Qualified Health Plan |
$17,340.78
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16,515.03
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$16,515.03
|
| Rate for Payer: Healthfirst Essential Plan |
$37,158.82
|
| Rate for Payer: Healthfirst QHP |
$16,515.03
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$16,515.03
|
| Rate for Payer: SOMOS Essential |
$37,158.82
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$37,158.82
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$18,166.53
|
| Rate for Payer: United Healthcare Medicaid |
$16,515.03
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$16,515.03
|
|
|
OUTPATIENT EAPG 00340: THERAPEUTIC NUCLEAR MEDICINE
|
Facility
|
OP
|
$1,004.94
|
|
|
Service Code
|
EAPG 00340
|
| Hospital Charge Code |
EAPG 00340
|
| Min. Negotiated Rate |
$446.64 |
| Max. Negotiated Rate |
$1,004.94 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,004.94
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,004.94
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$446.64
|
| Rate for Payer: Amida Care Medicaid |
$446.64
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$446.64
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,004.94
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,004.94
|
| Rate for Payer: Fidelis Qualified Health Plan |
$468.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$446.64
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$446.64
|
| Rate for Payer: Healthfirst Commercial |
$676.81
|
| Rate for Payer: Healthfirst Essential Plan |
$1,004.94
|
| Rate for Payer: Healthfirst QHP |
$446.64
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$446.64
|
| Rate for Payer: SOMOS Essential |
$1,004.94
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$1,004.94
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$491.30
|
| Rate for Payer: United Healthcare Medicaid |
$446.64
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$446.64
|
|
|
OUTPATIENT EAPG 00343: LEVEL I RADIATION THERAPY
|
Facility
|
OP
|
$900.74
|
|
|
Service Code
|
EAPG 00343
|
| Hospital Charge Code |
EAPG 00343
|
| Min. Negotiated Rate |
$400.33 |
| Max. Negotiated Rate |
$900.74 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$900.74
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$900.74
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$400.33
|
| Rate for Payer: Amida Care Medicaid |
$400.33
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$400.33
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$900.74
|
| Rate for Payer: Fidelis Essential Plan QHP |
$900.74
|
| Rate for Payer: Fidelis Qualified Health Plan |
$420.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$400.33
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$400.33
|
| Rate for Payer: Healthfirst Commercial |
$606.64
|
| Rate for Payer: Healthfirst Essential Plan |
$900.74
|
| Rate for Payer: Healthfirst QHP |
$400.33
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$400.33
|
| Rate for Payer: SOMOS Essential |
$900.74
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$900.74
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$440.36
|
| Rate for Payer: United Healthcare Medicaid |
$400.33
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$400.33
|
|
|
OUTPATIENT EAPG 00346: RADIOSURGERY
|
Facility
|
OP
|
$12,352.16
|
|
|
Service Code
|
EAPG 00346
|
| Hospital Charge Code |
EAPG 00346
|
| Min. Negotiated Rate |
$5,489.85 |
| Max. Negotiated Rate |
$12,352.16 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$12,352.16
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$12,352.16
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$5,489.85
|
| Rate for Payer: Amida Care Medicaid |
$5,489.85
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$5,489.85
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$12,352.16
|
| Rate for Payer: Fidelis Essential Plan QHP |
$12,352.16
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5,764.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5,489.85
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$5,489.85
|
| Rate for Payer: Healthfirst Commercial |
$8,318.97
|
| Rate for Payer: Healthfirst Essential Plan |
$12,352.16
|
| Rate for Payer: Healthfirst QHP |
$5,489.85
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$5,489.85
|
| Rate for Payer: SOMOS Essential |
$12,352.16
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$12,352.16
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$6,038.84
|
| Rate for Payer: United Healthcare Medicaid |
$5,489.85
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5,489.85
|
|
|
OUTPATIENT EAPG 00347: LEVEL II RADIATION THERAPY
|
Facility
|
OP
|
$414.58
|
|
|
Service Code
|
EAPG 00347
|
| Hospital Charge Code |
EAPG 00347
|
| Min. Negotiated Rate |
$184.26 |
| Max. Negotiated Rate |
$414.58 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$414.58
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$414.58
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$184.26
|
| Rate for Payer: Amida Care Medicaid |
$184.26
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$184.26
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$414.58
|
| Rate for Payer: Fidelis Essential Plan QHP |
$414.58
|
| Rate for Payer: Fidelis Qualified Health Plan |
$193.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$184.26
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$184.26
|
| Rate for Payer: Healthfirst Commercial |
$279.22
|
| Rate for Payer: Healthfirst Essential Plan |
$414.58
|
| Rate for Payer: Healthfirst QHP |
$184.26
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$184.26
|
| Rate for Payer: SOMOS Essential |
$414.58
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$414.58
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$202.69
|
| Rate for Payer: United Healthcare Medicaid |
$184.26
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$184.26
|
|
|
OUTPATIENT EAPG 00348: LEVEL III RADIATION THERAPY
|
Facility
|
OP
|
$1,992.98
|
|
|
Service Code
|
EAPG 00348
|
| Hospital Charge Code |
EAPG 00348
|
| Min. Negotiated Rate |
$885.77 |
| Max. Negotiated Rate |
$1,992.98 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,992.98
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,992.98
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$885.77
|
| Rate for Payer: Amida Care Medicaid |
$885.77
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$885.77
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,992.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,992.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$930.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$885.77
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$885.77
|
| Rate for Payer: Healthfirst Commercial |
$1,342.24
|
| Rate for Payer: Healthfirst Essential Plan |
$1,992.98
|
| Rate for Payer: Healthfirst QHP |
$885.77
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$885.77
|
| Rate for Payer: SOMOS Essential |
$1,992.98
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$1,992.98
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$974.35
|
| Rate for Payer: United Healthcare Medicaid |
$885.77
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$885.77
|
|
|
OUTPATIENT EAPG 00350: LEVEL I ADJUNCTIVE GENERAL DENTAL SERVICES
|
Facility
|
OP
|
$219.60
|
|
|
Service Code
|
EAPG 00350
|
| Hospital Charge Code |
EAPG 00350
|
| Min. Negotiated Rate |
$97.60 |
| Max. Negotiated Rate |
$219.60 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$219.60
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$219.60
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$97.60
|
| Rate for Payer: Amida Care Medicaid |
$97.60
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$97.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$219.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$219.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$102.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$97.60
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$97.60
|
| Rate for Payer: Healthfirst Commercial |
$147.91
|
| Rate for Payer: Healthfirst Essential Plan |
$219.60
|
| Rate for Payer: Healthfirst QHP |
$97.60
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$97.60
|
| Rate for Payer: SOMOS Essential |
$219.60
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$219.60
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$107.36
|
| Rate for Payer: United Healthcare Medicaid |
$97.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$97.60
|
|
|
OUTPATIENT EAPG 00351: LEVEL II ADJUNCTIVE GENERAL DENTAL SERVICES
|
Facility
|
OP
|
$618.84
|
|
|
Service Code
|
EAPG 00351
|
| Hospital Charge Code |
EAPG 00351
|
| Min. Negotiated Rate |
$275.04 |
| Max. Negotiated Rate |
$618.84 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$618.84
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$618.84
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$275.04
|
| Rate for Payer: Amida Care Medicaid |
$275.04
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$275.04
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$618.84
|
| Rate for Payer: Fidelis Essential Plan QHP |
$618.84
|
| Rate for Payer: Fidelis Qualified Health Plan |
$288.79
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$275.04
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$275.04
|
| Rate for Payer: Healthfirst Commercial |
$416.77
|
| Rate for Payer: Healthfirst Essential Plan |
$618.84
|
| Rate for Payer: Healthfirst QHP |
$275.04
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$275.04
|
| Rate for Payer: SOMOS Essential |
$618.84
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$618.84
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$302.54
|
| Rate for Payer: United Healthcare Medicaid |
$275.04
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$275.04
|
|
|
OUTPATIENT EAPG 00352: LEVEL I PERIODONTICS
|
Facility
|
OP
|
$385.02
|
|
|
Service Code
|
EAPG 00352
|
| Hospital Charge Code |
EAPG 00352
|
| Min. Negotiated Rate |
$171.12 |
| Max. Negotiated Rate |
$385.02 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$385.02
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$385.02
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$171.12
|
| Rate for Payer: Amida Care Medicaid |
$171.12
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$171.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$385.02
|
| Rate for Payer: Fidelis Essential Plan QHP |
$385.02
|
| Rate for Payer: Fidelis Qualified Health Plan |
$179.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$171.12
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$171.12
|
| Rate for Payer: Healthfirst Commercial |
$259.30
|
| Rate for Payer: Healthfirst Essential Plan |
$385.02
|
| Rate for Payer: Healthfirst QHP |
$171.12
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$171.12
|
| Rate for Payer: SOMOS Essential |
$385.02
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$385.02
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$188.23
|
| Rate for Payer: United Healthcare Medicaid |
$171.12
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$171.12
|
|
|
OUTPATIENT EAPG 00353: LEVEL I PROSTHODONTICS, FIXED
|
Facility
|
OP
|
$215.39
|
|
|
Service Code
|
EAPG 00353
|
| Hospital Charge Code |
EAPG 00353
|
| Min. Negotiated Rate |
$95.73 |
| Max. Negotiated Rate |
$215.39 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$215.39
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$215.39
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$95.73
|
| Rate for Payer: Amida Care Medicaid |
$95.73
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$95.73
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$215.39
|
| Rate for Payer: Fidelis Essential Plan QHP |
$215.39
|
| Rate for Payer: Fidelis Qualified Health Plan |
$100.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$95.73
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$95.73
|
| Rate for Payer: Healthfirst Commercial |
$145.05
|
| Rate for Payer: Healthfirst Essential Plan |
$215.39
|
| Rate for Payer: Healthfirst QHP |
$95.73
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$95.73
|
| Rate for Payer: SOMOS Essential |
$215.39
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$215.39
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$105.30
|
| Rate for Payer: United Healthcare Medicaid |
$95.73
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$95.73
|
|
|
OUTPATIENT EAPG 00354: LEVEL II PROSTHODONTICS, FIXED
|
Facility
|
OP
|
$805.72
|
|
|
Service Code
|
EAPG 00354
|
| Hospital Charge Code |
EAPG 00354
|
| Min. Negotiated Rate |
$358.10 |
| Max. Negotiated Rate |
$805.72 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$805.72
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$805.72
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$358.10
|
| Rate for Payer: Amida Care Medicaid |
$358.10
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$358.10
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$805.72
|
| Rate for Payer: Fidelis Essential Plan QHP |
$805.72
|
| Rate for Payer: Fidelis Qualified Health Plan |
$376.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$358.10
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$358.10
|
| Rate for Payer: Healthfirst Commercial |
$542.64
|
| Rate for Payer: Healthfirst Essential Plan |
$805.72
|
| Rate for Payer: Healthfirst QHP |
$358.10
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$358.10
|
| Rate for Payer: SOMOS Essential |
$805.72
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$805.72
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$393.91
|
| Rate for Payer: United Healthcare Medicaid |
$358.10
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$358.10
|
|
|
OUTPATIENT EAPG 00355: LEVEL III PROSTHODONTICS, FIXED
|
Facility
|
OP
|
$996.70
|
|
|
Service Code
|
EAPG 00355
|
| Hospital Charge Code |
EAPG 00355
|
| Min. Negotiated Rate |
$442.98 |
| Max. Negotiated Rate |
$996.70 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$996.70
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$996.70
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$442.98
|
| Rate for Payer: Amida Care Medicaid |
$442.98
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$442.98
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$996.70
|
| Rate for Payer: Fidelis Essential Plan QHP |
$996.70
|
| Rate for Payer: Fidelis Qualified Health Plan |
$465.13
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$442.98
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$442.98
|
| Rate for Payer: Healthfirst Commercial |
$671.27
|
| Rate for Payer: Healthfirst Essential Plan |
$996.70
|
| Rate for Payer: Healthfirst QHP |
$442.98
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$442.98
|
| Rate for Payer: SOMOS Essential |
$996.70
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$996.70
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$487.28
|
| Rate for Payer: United Healthcare Medicaid |
$442.98
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$442.98
|
|
|
OUTPATIENT EAPG 00356: LEVEL I PROSTHODONTICS, REMOVABLE
|
Facility
|
OP
|
$436.52
|
|
|
Service Code
|
EAPG 00356
|
| Hospital Charge Code |
EAPG 00356
|
| Min. Negotiated Rate |
$194.01 |
| Max. Negotiated Rate |
$436.52 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$436.52
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$436.52
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$194.01
|
| Rate for Payer: Amida Care Medicaid |
$194.01
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$194.01
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$436.52
|
| Rate for Payer: Fidelis Essential Plan QHP |
$436.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$203.71
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$194.01
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$194.01
|
| Rate for Payer: Healthfirst Commercial |
$293.99
|
| Rate for Payer: Healthfirst Essential Plan |
$436.52
|
| Rate for Payer: Healthfirst QHP |
$194.01
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$194.01
|
| Rate for Payer: SOMOS Essential |
$436.52
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$436.52
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$213.41
|
| Rate for Payer: United Healthcare Medicaid |
$194.01
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$194.01
|
|
|
OUTPATIENT EAPG 00357: LEVEL II PROSTHODONTICS, REMOVABLE
|
Facility
|
OP
|
$835.22
|
|
|
Service Code
|
EAPG 00357
|
| Hospital Charge Code |
EAPG 00357
|
| Min. Negotiated Rate |
$371.21 |
| Max. Negotiated Rate |
$835.22 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$835.22
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$835.22
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$371.21
|
| Rate for Payer: Amida Care Medicaid |
$371.21
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$371.21
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$835.22
|
| Rate for Payer: Fidelis Essential Plan QHP |
$835.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$389.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$371.21
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$371.21
|
| Rate for Payer: Healthfirst Commercial |
$562.50
|
| Rate for Payer: Healthfirst Essential Plan |
$835.22
|
| Rate for Payer: Healthfirst QHP |
$371.21
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$371.21
|
| Rate for Payer: SOMOS Essential |
$835.22
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$835.22
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$408.33
|
| Rate for Payer: United Healthcare Medicaid |
$371.21
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$371.21
|
|
|
OUTPATIENT EAPG 00358: LEVEL III PROSTHODONTICS, REMOVABLE
|
Facility
|
OP
|
$642.85
|
|
|
Service Code
|
EAPG 00358
|
| Hospital Charge Code |
EAPG 00358
|
| Min. Negotiated Rate |
$285.71 |
| Max. Negotiated Rate |
$642.85 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$642.85
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$642.85
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$285.71
|
| Rate for Payer: Amida Care Medicaid |
$285.71
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$285.71
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$642.85
|
| Rate for Payer: Fidelis Essential Plan QHP |
$642.85
|
| Rate for Payer: Fidelis Qualified Health Plan |
$300.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$285.71
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$285.71
|
| Rate for Payer: Healthfirst Commercial |
$432.94
|
| Rate for Payer: Healthfirst Essential Plan |
$642.85
|
| Rate for Payer: Healthfirst QHP |
$285.71
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$285.71
|
| Rate for Payer: SOMOS Essential |
$642.85
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$642.85
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$314.28
|
| Rate for Payer: United Healthcare Medicaid |
$285.71
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$285.71
|
|
|
OUTPATIENT EAPG 00359: LEVEL I MAXILLOFACIAL PROSTHETICS
|
Facility
|
OP
|
$121.28
|
|
|
Service Code
|
EAPG 00359
|
| Hospital Charge Code |
EAPG 00359
|
| Min. Negotiated Rate |
$53.90 |
| Max. Negotiated Rate |
$121.28 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$121.28
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$121.28
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$53.90
|
| Rate for Payer: Amida Care Medicaid |
$53.90
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$53.90
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$121.28
|
| Rate for Payer: Fidelis Essential Plan QHP |
$121.28
|
| Rate for Payer: Fidelis Qualified Health Plan |
$56.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$53.90
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$53.90
|
| Rate for Payer: Healthfirst Commercial |
$81.68
|
| Rate for Payer: Healthfirst Essential Plan |
$121.28
|
| Rate for Payer: Healthfirst QHP |
$53.90
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$53.90
|
| Rate for Payer: SOMOS Essential |
$121.28
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$121.28
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$59.29
|
| Rate for Payer: United Healthcare Medicaid |
$53.90
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$53.90
|
|
|
OUTPATIENT EAPG 00360: LEVEL II MAXILLOFACIAL PROSTHETICS
|
Facility
|
OP
|
$633.35
|
|
|
Service Code
|
EAPG 00360
|
| Hospital Charge Code |
EAPG 00360
|
| Min. Negotiated Rate |
$281.49 |
| Max. Negotiated Rate |
$633.35 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$633.35
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$633.35
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$281.49
|
| Rate for Payer: Amida Care Medicaid |
$281.49
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$281.49
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$633.35
|
| Rate for Payer: Fidelis Essential Plan QHP |
$633.35
|
| Rate for Payer: Fidelis Qualified Health Plan |
$295.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$281.49
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$281.49
|
| Rate for Payer: Healthfirst Commercial |
$426.54
|
| Rate for Payer: Healthfirst Essential Plan |
$633.35
|
| Rate for Payer: Healthfirst QHP |
$281.49
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$281.49
|
| Rate for Payer: SOMOS Essential |
$633.35
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$633.35
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$309.64
|
| Rate for Payer: United Healthcare Medicaid |
$281.49
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$281.49
|
|
