St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

OUTPATIENT EAPG 00361: LEVEL I DENTAL RESTORATIONS

Facility

$310.57

Service Code	EAPG 00361
Hospital Charge Code	EAPG 00361
Min. Negotiated Rate	$138.03
Max. Negotiated Rate	$310.57
Rate for Payer: Affinity Essential Plan 1&2	$310.57
Rate for Payer: Affinity Essential Plan 3&4	$310.57
Rate for Payer: Affinity Medicaid/CHP/HARP	$138.03
Rate for Payer: Amida Care Medicaid	$138.03
Rate for Payer: Fidelis CHP/HARP/Medicaid	$138.03
Rate for Payer: Fidelis Essential Plan Aliesa	$310.57
Rate for Payer: Fidelis Essential Plan QHP	$310.57
Rate for Payer: Fidelis Qualified Health Plan	$144.93
Rate for Payer: Hamaspik Choice Inc Medicaid	$138.03
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$138.03
Rate for Payer: Healthfirst Commercial	$209.16
Rate for Payer: Healthfirst Essential Plan	$310.57
Rate for Payer: Healthfirst QHP	$138.03
Rate for Payer: SOMOS CHP/HARP/Medicaid	$138.03
Rate for Payer: SOMOS Essential	$310.57
Rate for Payer: United Healthcare Essential Plan 1&2	$310.57
Rate for Payer: United Healthcare Essential Plan 3&4	$151.83
Rate for Payer: United Healthcare Medicaid	$138.03
Rate for Payer: Wellcare CHP/FHP/Medicaid	$138.03

OUTPATIENT EAPG 00362: LEVEL II DENTAL RESTORATIONS

Facility

$465.98

Service Code	EAPG 00362
Hospital Charge Code	EAPG 00362
Min. Negotiated Rate	$207.10
Max. Negotiated Rate	$465.98
Rate for Payer: Affinity Essential Plan 1&2	$465.98
Rate for Payer: Affinity Essential Plan 3&4	$465.98
Rate for Payer: Affinity Medicaid/CHP/HARP	$207.10
Rate for Payer: Amida Care Medicaid	$207.10
Rate for Payer: Fidelis CHP/HARP/Medicaid	$207.10
Rate for Payer: Fidelis Essential Plan Aliesa	$465.98
Rate for Payer: Fidelis Essential Plan QHP	$465.98
Rate for Payer: Fidelis Qualified Health Plan	$217.46
Rate for Payer: Hamaspik Choice Inc Medicaid	$207.10
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$207.10
Rate for Payer: Healthfirst Commercial	$313.82
Rate for Payer: Healthfirst Essential Plan	$465.98
Rate for Payer: Healthfirst QHP	$207.10
Rate for Payer: SOMOS CHP/HARP/Medicaid	$207.10
Rate for Payer: SOMOS Essential	$465.98
Rate for Payer: United Healthcare Essential Plan 1&2	$465.98
Rate for Payer: United Healthcare Essential Plan 3&4	$227.81
Rate for Payer: United Healthcare Medicaid	$207.10
Rate for Payer: Wellcare CHP/FHP/Medicaid	$207.10

OUTPATIENT EAPG 00363: LEVEL III DENTAL RESTORATION

Facility

$1,111.21

Service Code	EAPG 00363
Hospital Charge Code	EAPG 00363
Min. Negotiated Rate	$493.87
Max. Negotiated Rate	$1,111.21
Rate for Payer: Affinity Essential Plan 1&2	$1,111.21
Rate for Payer: Affinity Essential Plan 3&4	$1,111.21
Rate for Payer: Affinity Medicaid/CHP/HARP	$493.87
Rate for Payer: Amida Care Medicaid	$493.87
Rate for Payer: Fidelis CHP/HARP/Medicaid	$493.87
Rate for Payer: Fidelis Essential Plan Aliesa	$1,111.21
Rate for Payer: Fidelis Essential Plan QHP	$1,111.21
Rate for Payer: Fidelis Qualified Health Plan	$518.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$493.87
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$493.87
Rate for Payer: Healthfirst Commercial	$748.38
Rate for Payer: Healthfirst Essential Plan	$1,111.21
Rate for Payer: Healthfirst QHP	$493.87
Rate for Payer: SOMOS CHP/HARP/Medicaid	$493.87
Rate for Payer: SOMOS Essential	$1,111.21
Rate for Payer: United Healthcare Essential Plan 1&2	$1,111.21
Rate for Payer: United Healthcare Essential Plan 3&4	$543.26
Rate for Payer: United Healthcare Medicaid	$493.87
Rate for Payer: Wellcare CHP/FHP/Medicaid	$493.87

OUTPATIENT EAPG 00364: LEVEL I ENDODONTICS

Facility

$295.92

Service Code	EAPG 00364
Hospital Charge Code	EAPG 00364
Min. Negotiated Rate	$131.52
Max. Negotiated Rate	$295.92
Rate for Payer: Affinity Essential Plan 1&2	$295.92
Rate for Payer: Affinity Essential Plan 3&4	$295.92
Rate for Payer: Affinity Medicaid/CHP/HARP	$131.52
Rate for Payer: Amida Care Medicaid	$131.52
Rate for Payer: Fidelis CHP/HARP/Medicaid	$131.52
Rate for Payer: Fidelis Essential Plan Aliesa	$295.92
Rate for Payer: Fidelis Essential Plan QHP	$295.92
Rate for Payer: Fidelis Qualified Health Plan	$138.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$131.52
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$131.52
Rate for Payer: Healthfirst Commercial	$199.30
Rate for Payer: Healthfirst Essential Plan	$295.92
Rate for Payer: Healthfirst QHP	$131.52
Rate for Payer: SOMOS CHP/HARP/Medicaid	$131.52
Rate for Payer: SOMOS Essential	$295.92
Rate for Payer: United Healthcare Essential Plan 1&2	$295.92
Rate for Payer: United Healthcare Essential Plan 3&4	$144.67
Rate for Payer: United Healthcare Medicaid	$131.52
Rate for Payer: Wellcare CHP/FHP/Medicaid	$131.52

OUTPATIENT EAPG 00365: LEVEL II ENDODONTICS

Facility

$532.12

Service Code	EAPG 00365
Hospital Charge Code	EAPG 00365
Min. Negotiated Rate	$236.50
Max. Negotiated Rate	$532.12
Rate for Payer: Affinity Essential Plan 1&2	$532.12
Rate for Payer: Affinity Essential Plan 3&4	$532.12
Rate for Payer: Affinity Medicaid/CHP/HARP	$236.50
Rate for Payer: Amida Care Medicaid	$236.50
Rate for Payer: Fidelis CHP/HARP/Medicaid	$236.50
Rate for Payer: Fidelis Essential Plan Aliesa	$532.12
Rate for Payer: Fidelis Essential Plan QHP	$532.12
Rate for Payer: Fidelis Qualified Health Plan	$248.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$236.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$236.50
Rate for Payer: Healthfirst Commercial	$358.37
Rate for Payer: Healthfirst Essential Plan	$532.12
Rate for Payer: Healthfirst QHP	$236.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$236.50
Rate for Payer: SOMOS Essential	$532.12
Rate for Payer: United Healthcare Essential Plan 1&2	$532.12
Rate for Payer: United Healthcare Essential Plan 3&4	$260.15
Rate for Payer: United Healthcare Medicaid	$236.50
Rate for Payer: Wellcare CHP/FHP/Medicaid	$236.50

OUTPATIENT EAPG 00366: LEVEL III ENDODONTICS

Facility

$536.04

Service Code	EAPG 00366
Hospital Charge Code	EAPG 00366
Min. Negotiated Rate	$238.24
Max. Negotiated Rate	$536.04
Rate for Payer: Affinity Essential Plan 1&2	$536.04
Rate for Payer: Affinity Essential Plan 3&4	$536.04
Rate for Payer: Affinity Medicaid/CHP/HARP	$238.24
Rate for Payer: Amida Care Medicaid	$238.24
Rate for Payer: Fidelis CHP/HARP/Medicaid	$238.24
Rate for Payer: Fidelis Essential Plan Aliesa	$536.04
Rate for Payer: Fidelis Essential Plan QHP	$536.04
Rate for Payer: Fidelis Qualified Health Plan	$250.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$238.24
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$238.24
Rate for Payer: Healthfirst Commercial	$361.01
Rate for Payer: Healthfirst Essential Plan	$536.04
Rate for Payer: Healthfirst QHP	$238.24
Rate for Payer: SOMOS CHP/HARP/Medicaid	$238.24
Rate for Payer: SOMOS Essential	$536.04
Rate for Payer: United Healthcare Essential Plan 1&2	$536.04
Rate for Payer: United Healthcare Essential Plan 3&4	$262.06
Rate for Payer: United Healthcare Medicaid	$238.24
Rate for Payer: Wellcare CHP/FHP/Medicaid	$238.24

OUTPATIENT EAPG 00367: LEVEL I ORAL AND MAXILLOFACIAL SURGERY

Facility

$354.62

Service Code	EAPG 00367
Hospital Charge Code	EAPG 00367
Min. Negotiated Rate	$157.61
Max. Negotiated Rate	$354.62
Rate for Payer: Affinity Essential Plan 1&2	$354.62
Rate for Payer: Affinity Essential Plan 3&4	$354.62
Rate for Payer: Affinity Medicaid/CHP/HARP	$157.61
Rate for Payer: Amida Care Medicaid	$157.61
Rate for Payer: Fidelis CHP/HARP/Medicaid	$157.61
Rate for Payer: Fidelis Essential Plan Aliesa	$354.62
Rate for Payer: Fidelis Essential Plan QHP	$354.62
Rate for Payer: Fidelis Qualified Health Plan	$165.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$157.61
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$157.61
Rate for Payer: Healthfirst Commercial	$238.83
Rate for Payer: Healthfirst Essential Plan	$354.62
Rate for Payer: Healthfirst QHP	$157.61
Rate for Payer: SOMOS CHP/HARP/Medicaid	$157.61
Rate for Payer: SOMOS Essential	$354.62
Rate for Payer: United Healthcare Essential Plan 1&2	$354.62
Rate for Payer: United Healthcare Essential Plan 3&4	$173.37
Rate for Payer: United Healthcare Medicaid	$157.61
Rate for Payer: Wellcare CHP/FHP/Medicaid	$157.61

OUTPATIENT EAPG 00368: LEVEL II ORAL AND MAXILLOFACIAL SURGERY

Facility

$982.28

Service Code	EAPG 00368
Hospital Charge Code	EAPG 00368
Min. Negotiated Rate	$436.57
Max. Negotiated Rate	$982.28
Rate for Payer: Affinity Essential Plan 1&2	$982.28
Rate for Payer: Affinity Essential Plan 3&4	$982.28
Rate for Payer: Affinity Medicaid/CHP/HARP	$436.57
Rate for Payer: Amida Care Medicaid	$436.57
Rate for Payer: Fidelis CHP/HARP/Medicaid	$436.57
Rate for Payer: Fidelis Essential Plan Aliesa	$982.28
Rate for Payer: Fidelis Essential Plan QHP	$982.28
Rate for Payer: Fidelis Qualified Health Plan	$458.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$436.57
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$436.57
Rate for Payer: Healthfirst Commercial	$661.55
Rate for Payer: Healthfirst Essential Plan	$982.28
Rate for Payer: Healthfirst QHP	$436.57
Rate for Payer: SOMOS CHP/HARP/Medicaid	$436.57
Rate for Payer: SOMOS Essential	$982.28
Rate for Payer: United Healthcare Essential Plan 1&2	$982.28
Rate for Payer: United Healthcare Essential Plan 3&4	$480.23
Rate for Payer: United Healthcare Medicaid	$436.57
Rate for Payer: Wellcare CHP/FHP/Medicaid	$436.57

OUTPATIENT EAPG 00369: LEVEL III ORAL AND MAXILLOFACIAL SURGERY

Facility

$982.28

Service Code	EAPG 00369
Hospital Charge Code	EAPG 00369
Min. Negotiated Rate	$436.57
Max. Negotiated Rate	$982.28
Rate for Payer: Affinity Essential Plan 1&2	$982.28
Rate for Payer: Affinity Essential Plan 3&4	$982.28
Rate for Payer: Affinity Medicaid/CHP/HARP	$436.57
Rate for Payer: Amida Care Medicaid	$436.57
Rate for Payer: Fidelis CHP/HARP/Medicaid	$436.57
Rate for Payer: Fidelis Essential Plan Aliesa	$982.28
Rate for Payer: Fidelis Essential Plan QHP	$982.28
Rate for Payer: Fidelis Qualified Health Plan	$458.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$436.57
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$436.57
Rate for Payer: Healthfirst Commercial	$661.55
Rate for Payer: Healthfirst Essential Plan	$982.28
Rate for Payer: Healthfirst QHP	$436.57
Rate for Payer: SOMOS CHP/HARP/Medicaid	$436.57
Rate for Payer: SOMOS Essential	$982.28
Rate for Payer: United Healthcare Essential Plan 1&2	$982.28
Rate for Payer: United Healthcare Essential Plan 3&4	$480.23
Rate for Payer: United Healthcare Medicaid	$436.57
Rate for Payer: Wellcare CHP/FHP/Medicaid	$436.57

OUTPATIENT EAPG 00370: LEVEL IV ORAL AND MAXILLOFACIAL SURGERY

Facility

$982.28

Service Code	EAPG 00370
Hospital Charge Code	EAPG 00370
Min. Negotiated Rate	$436.57
Max. Negotiated Rate	$982.28
Rate for Payer: Affinity Essential Plan 1&2	$982.28
Rate for Payer: Affinity Essential Plan 3&4	$982.28
Rate for Payer: Affinity Medicaid/CHP/HARP	$436.57
Rate for Payer: Amida Care Medicaid	$436.57
Rate for Payer: Fidelis CHP/HARP/Medicaid	$436.57
Rate for Payer: Fidelis Essential Plan Aliesa	$982.28
Rate for Payer: Fidelis Essential Plan QHP	$982.28
Rate for Payer: Fidelis Qualified Health Plan	$458.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$436.57
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$436.57
Rate for Payer: Healthfirst Commercial	$661.55
Rate for Payer: Healthfirst Essential Plan	$982.28
Rate for Payer: Healthfirst QHP	$436.57
Rate for Payer: SOMOS CHP/HARP/Medicaid	$436.57
Rate for Payer: SOMOS Essential	$982.28
Rate for Payer: United Healthcare Essential Plan 1&2	$982.28
Rate for Payer: United Healthcare Essential Plan 3&4	$480.23
Rate for Payer: United Healthcare Medicaid	$436.57
Rate for Payer: Wellcare CHP/FHP/Medicaid	$436.57

OUTPATIENT EAPG 00372: SEALANT

Facility

$97.09

Service Code	EAPG 00372
Hospital Charge Code	EAPG 00372
Min. Negotiated Rate	$43.15
Max. Negotiated Rate	$97.09
Rate for Payer: Affinity Essential Plan 1&2	$97.09
Rate for Payer: Affinity Essential Plan 3&4	$97.09
Rate for Payer: Affinity Medicaid/CHP/HARP	$43.15
Rate for Payer: Amida Care Medicaid	$43.15
Rate for Payer: Fidelis CHP/HARP/Medicaid	$43.15
Rate for Payer: Fidelis Essential Plan Aliesa	$97.09
Rate for Payer: Fidelis Essential Plan QHP	$97.09
Rate for Payer: Fidelis Qualified Health Plan	$45.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$43.15
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$43.15
Rate for Payer: Healthfirst Commercial	$65.40
Rate for Payer: Healthfirst Essential Plan	$97.09
Rate for Payer: Healthfirst QHP	$43.15
Rate for Payer: SOMOS CHP/HARP/Medicaid	$43.15
Rate for Payer: SOMOS Essential	$97.09
Rate for Payer: United Healthcare Essential Plan 1&2	$97.09
Rate for Payer: United Healthcare Essential Plan 3&4	$47.46
Rate for Payer: United Healthcare Medicaid	$43.15
Rate for Payer: Wellcare CHP/FHP/Medicaid	$43.15

OUTPATIENT EAPG 00373: LEVEL I DENTAL FILM

Facility

$63.34

Service Code	EAPG 00373
Hospital Charge Code	EAPG 00373
Min. Negotiated Rate	$28.15
Max. Negotiated Rate	$63.34
Rate for Payer: Affinity Essential Plan 1&2	$63.34
Rate for Payer: Affinity Essential Plan 3&4	$63.34
Rate for Payer: Affinity Medicaid/CHP/HARP	$28.15
Rate for Payer: Amida Care Medicaid	$28.15
Rate for Payer: Fidelis CHP/HARP/Medicaid	$28.15
Rate for Payer: Fidelis Essential Plan Aliesa	$63.34
Rate for Payer: Fidelis Essential Plan QHP	$63.34
Rate for Payer: Fidelis Qualified Health Plan	$29.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$28.15
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$28.15
Rate for Payer: Healthfirst Commercial	$42.66
Rate for Payer: Healthfirst Essential Plan	$63.34
Rate for Payer: Healthfirst QHP	$28.15
Rate for Payer: SOMOS CHP/HARP/Medicaid	$28.15
Rate for Payer: SOMOS Essential	$63.34
Rate for Payer: United Healthcare Essential Plan 1&2	$63.34
Rate for Payer: United Healthcare Essential Plan 3&4	$30.96
Rate for Payer: United Healthcare Medicaid	$28.15
Rate for Payer: Wellcare CHP/FHP/Medicaid	$28.15

OUTPATIENT EAPG 00374: LEVEL II DENTAL FILM

Facility

$219.22

Service Code	EAPG 00374
Hospital Charge Code	EAPG 00374
Min. Negotiated Rate	$97.43
Max. Negotiated Rate	$219.22
Rate for Payer: Affinity Essential Plan 1&2	$219.22
Rate for Payer: Affinity Essential Plan 3&4	$219.22
Rate for Payer: Affinity Medicaid/CHP/HARP	$97.43
Rate for Payer: Amida Care Medicaid	$97.43
Rate for Payer: Fidelis CHP/HARP/Medicaid	$97.43
Rate for Payer: Fidelis Essential Plan Aliesa	$219.22
Rate for Payer: Fidelis Essential Plan QHP	$219.22
Rate for Payer: Fidelis Qualified Health Plan	$102.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$97.43
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$97.43
Rate for Payer: Healthfirst Commercial	$147.65
Rate for Payer: Healthfirst Essential Plan	$219.22
Rate for Payer: Healthfirst QHP	$97.43
Rate for Payer: SOMOS CHP/HARP/Medicaid	$97.43
Rate for Payer: SOMOS Essential	$219.22
Rate for Payer: United Healthcare Essential Plan 1&2	$219.22
Rate for Payer: United Healthcare Essential Plan 3&4	$107.17
Rate for Payer: United Healthcare Medicaid	$97.43
Rate for Payer: Wellcare CHP/FHP/Medicaid	$97.43

OUTPATIENT EAPG 00375: DENTAL ANESTHESIA

Facility

$2,674.87

Service Code	EAPG 00375
Hospital Charge Code	EAPG 00375
Min. Negotiated Rate	$1,188.83
Max. Negotiated Rate	$2,674.87
Rate for Payer: Affinity Essential Plan 1&2	$2,674.87
Rate for Payer: Affinity Essential Plan 3&4	$2,674.87
Rate for Payer: Affinity Medicaid/CHP/HARP	$1,188.83
Rate for Payer: Amida Care Medicaid	$1,188.83
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1,188.83
Rate for Payer: Fidelis Essential Plan Aliesa	$2,674.87
Rate for Payer: Fidelis Essential Plan QHP	$2,674.87
Rate for Payer: Fidelis Qualified Health Plan	$1,248.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,188.83
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1,188.83
Rate for Payer: Healthfirst Commercial	$1,801.48
Rate for Payer: Healthfirst Essential Plan	$2,674.87
Rate for Payer: Healthfirst QHP	$1,188.83
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1,188.83
Rate for Payer: SOMOS Essential	$2,674.87
Rate for Payer: United Healthcare Essential Plan 1&2	$2,674.87
Rate for Payer: United Healthcare Essential Plan 3&4	$1,307.71
Rate for Payer: United Healthcare Medicaid	$1,188.83
Rate for Payer: Wellcare CHP/FHP/Medicaid	$1,188.83

OUTPATIENT EAPG 00376: DIAGNOSTIC DENTAL PROCEDURES

Facility

$110.41

Service Code	EAPG 00376
Hospital Charge Code	EAPG 00376
Min. Negotiated Rate	$49.07
Max. Negotiated Rate	$110.41
Rate for Payer: Affinity Essential Plan 1&2	$110.41
Rate for Payer: Affinity Essential Plan 3&4	$110.41
Rate for Payer: Affinity Medicaid/CHP/HARP	$49.07
Rate for Payer: Amida Care Medicaid	$49.07
Rate for Payer: Fidelis CHP/HARP/Medicaid	$49.07
Rate for Payer: Fidelis Essential Plan Aliesa	$110.41
Rate for Payer: Fidelis Essential Plan QHP	$110.41
Rate for Payer: Fidelis Qualified Health Plan	$51.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$49.07
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$49.07
Rate for Payer: Healthfirst Commercial	$74.36
Rate for Payer: Healthfirst Essential Plan	$110.41
Rate for Payer: Healthfirst QHP	$49.07
Rate for Payer: SOMOS CHP/HARP/Medicaid	$49.07
Rate for Payer: SOMOS Essential	$110.41
Rate for Payer: United Healthcare Essential Plan 1&2	$110.41
Rate for Payer: United Healthcare Essential Plan 3&4	$53.98
Rate for Payer: United Healthcare Medicaid	$49.07
Rate for Payer: Wellcare CHP/FHP/Medicaid	$49.07

OUTPATIENT EAPG 00377: PREVENTIVE DENTAL PROCEDURES

Facility

$154.44

Service Code	EAPG 00377
Hospital Charge Code	EAPG 00377
Min. Negotiated Rate	$68.64
Max. Negotiated Rate	$154.44
Rate for Payer: Affinity Essential Plan 1&2	$154.44
Rate for Payer: Affinity Essential Plan 3&4	$154.44
Rate for Payer: Affinity Medicaid/CHP/HARP	$68.64
Rate for Payer: Amida Care Medicaid	$68.64
Rate for Payer: Fidelis CHP/HARP/Medicaid	$68.64
Rate for Payer: Fidelis Essential Plan Aliesa	$154.44
Rate for Payer: Fidelis Essential Plan QHP	$154.44
Rate for Payer: Fidelis Qualified Health Plan	$72.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$68.64
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$68.64
Rate for Payer: Healthfirst Commercial	$104.03
Rate for Payer: Healthfirst Essential Plan	$154.44
Rate for Payer: Healthfirst QHP	$68.64
Rate for Payer: SOMOS CHP/HARP/Medicaid	$68.64
Rate for Payer: SOMOS Essential	$154.44
Rate for Payer: United Healthcare Essential Plan 1&2	$154.44
Rate for Payer: United Healthcare Essential Plan 3&4	$75.50
Rate for Payer: United Healthcare Medicaid	$68.64
Rate for Payer: Wellcare CHP/FHP/Medicaid	$68.64

OUTPATIENT EAPG 00384: LEVEL III CHEMISTRY TESTS

Facility

$138.98

Service Code	EAPG 00384
Hospital Charge Code	EAPG 00384
Min. Negotiated Rate	$61.77
Max. Negotiated Rate	$138.98
Rate for Payer: Affinity Essential Plan 1&2	$138.98
Rate for Payer: Affinity Essential Plan 3&4	$138.98
Rate for Payer: Affinity Medicaid/CHP/HARP	$61.77
Rate for Payer: Amida Care Medicaid	$61.77
Rate for Payer: Fidelis CHP/HARP/Medicaid	$61.77
Rate for Payer: Fidelis Essential Plan Aliesa	$138.98
Rate for Payer: Fidelis Essential Plan QHP	$138.98
Rate for Payer: Fidelis Qualified Health Plan	$64.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$61.77
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$61.77
Rate for Payer: Healthfirst Essential Plan	$138.98
Rate for Payer: Healthfirst QHP	$61.77
Rate for Payer: SOMOS CHP/HARP/Medicaid	$61.77
Rate for Payer: SOMOS Essential	$138.98
Rate for Payer: United Healthcare Essential Plan 1&2	$138.98
Rate for Payer: United Healthcare Essential Plan 3&4	$67.95
Rate for Payer: United Healthcare Medicaid	$61.77
Rate for Payer: Wellcare CHP/FHP/Medicaid	$61.77

OUTPATIENT EAPG 00388: LEVEL III MICROBIOLOGY TESTS

Facility

$157.72

Service Code	EAPG 00388
Hospital Charge Code	EAPG 00388
Min. Negotiated Rate	$70.10
Max. Negotiated Rate	$157.72
Rate for Payer: Affinity Essential Plan 1&2	$157.72
Rate for Payer: Affinity Essential Plan 3&4	$157.72
Rate for Payer: Affinity Medicaid/CHP/HARP	$70.10
Rate for Payer: Amida Care Medicaid	$70.10
Rate for Payer: Fidelis CHP/HARP/Medicaid	$70.10
Rate for Payer: Fidelis Essential Plan Aliesa	$157.72
Rate for Payer: Fidelis Essential Plan QHP	$157.72
Rate for Payer: Fidelis Qualified Health Plan	$73.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$70.10
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$70.10
Rate for Payer: Healthfirst Essential Plan	$157.72
Rate for Payer: Healthfirst QHP	$70.10
Rate for Payer: SOMOS CHP/HARP/Medicaid	$70.10
Rate for Payer: SOMOS Essential	$157.72
Rate for Payer: United Healthcare Essential Plan 1&2	$157.72
Rate for Payer: United Healthcare Essential Plan 3&4	$77.11
Rate for Payer: United Healthcare Medicaid	$70.10
Rate for Payer: Wellcare CHP/FHP/Medicaid	$70.10

OUTPATIENT EAPG 00389: LEVEL II CONVENTIONAL RADIOLOGY

Facility

$659.41

Service Code	EAPG 00389
Hospital Charge Code	EAPG 00389
Min. Negotiated Rate	$293.07
Max. Negotiated Rate	$659.41
Rate for Payer: Affinity Essential Plan 1&2	$659.41
Rate for Payer: Affinity Essential Plan 3&4	$659.41
Rate for Payer: Affinity Medicaid/CHP/HARP	$293.07
Rate for Payer: Amida Care Medicaid	$293.07
Rate for Payer: Fidelis CHP/HARP/Medicaid	$293.07
Rate for Payer: Fidelis Essential Plan Aliesa	$659.41
Rate for Payer: Fidelis Essential Plan QHP	$659.41
Rate for Payer: Fidelis Qualified Health Plan	$307.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$293.07
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$293.07
Rate for Payer: Healthfirst Essential Plan	$659.41
Rate for Payer: Healthfirst QHP	$293.07
Rate for Payer: SOMOS CHP/HARP/Medicaid	$293.07
Rate for Payer: SOMOS Essential	$659.41
Rate for Payer: United Healthcare Essential Plan 1&2	$659.41
Rate for Payer: United Healthcare Essential Plan 3&4	$322.38
Rate for Payer: United Healthcare Medicaid	$293.07
Rate for Payer: Wellcare CHP/FHP/Medicaid	$293.07

OUTPATIENT EAPG 00390: LEVEL I PATHOLOGY

Facility

$110.02

Service Code	EAPG 00390
Hospital Charge Code	EAPG 00390
Min. Negotiated Rate	$48.90
Max. Negotiated Rate	$110.02
Rate for Payer: Affinity Essential Plan 1&2	$110.02
Rate for Payer: Affinity Essential Plan 3&4	$110.02
Rate for Payer: Affinity Medicaid/CHP/HARP	$48.90
Rate for Payer: Amida Care Medicaid	$48.90
Rate for Payer: Fidelis CHP/HARP/Medicaid	$48.90
Rate for Payer: Fidelis Essential Plan Aliesa	$110.02
Rate for Payer: Fidelis Essential Plan QHP	$110.02
Rate for Payer: Fidelis Qualified Health Plan	$51.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$48.90
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$48.90
Rate for Payer: Healthfirst Commercial	$74.10
Rate for Payer: Healthfirst Essential Plan	$110.02
Rate for Payer: Healthfirst QHP	$48.90
Rate for Payer: SOMOS CHP/HARP/Medicaid	$48.90
Rate for Payer: SOMOS Essential	$110.02
Rate for Payer: United Healthcare Essential Plan 1&2	$110.02
Rate for Payer: United Healthcare Essential Plan 3&4	$53.79
Rate for Payer: United Healthcare Medicaid	$48.90
Rate for Payer: Wellcare CHP/FHP/Medicaid	$48.90

OUTPATIENT EAPG 00391: LEVEL II PATHOLOGY TESTS

Facility

$204.73

Service Code	EAPG 00391
Hospital Charge Code	EAPG 00391
Min. Negotiated Rate	$90.99
Max. Negotiated Rate	$204.73
Rate for Payer: Affinity Essential Plan 1&2	$204.73
Rate for Payer: Affinity Essential Plan 3&4	$204.73
Rate for Payer: Affinity Medicaid/CHP/HARP	$90.99
Rate for Payer: Amida Care Medicaid	$90.99
Rate for Payer: Fidelis CHP/HARP/Medicaid	$90.99
Rate for Payer: Fidelis Essential Plan Aliesa	$204.73
Rate for Payer: Fidelis Essential Plan QHP	$204.73
Rate for Payer: Fidelis Qualified Health Plan	$95.54
Rate for Payer: Hamaspik Choice Inc Medicaid	$90.99
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$90.99
Rate for Payer: Healthfirst Commercial	$137.88
Rate for Payer: Healthfirst Essential Plan	$204.73
Rate for Payer: Healthfirst QHP	$90.99
Rate for Payer: SOMOS CHP/HARP/Medicaid	$90.99
Rate for Payer: SOMOS Essential	$204.73
Rate for Payer: United Healthcare Essential Plan 1&2	$204.73
Rate for Payer: United Healthcare Essential Plan 3&4	$100.09
Rate for Payer: United Healthcare Medicaid	$90.99
Rate for Payer: Wellcare CHP/FHP/Medicaid	$90.99

OUTPATIENT EAPG 00392: PAP SMEARS

Facility

$85.57

Service Code	EAPG 00392
Hospital Charge Code	EAPG 00392
Min. Negotiated Rate	$38.03
Max. Negotiated Rate	$85.57
Rate for Payer: Affinity Essential Plan 1&2	$85.57
Rate for Payer: Affinity Essential Plan 3&4	$85.57
Rate for Payer: Affinity Medicaid/CHP/HARP	$38.03
Rate for Payer: Amida Care Medicaid	$38.03
Rate for Payer: Fidelis CHP/HARP/Medicaid	$38.03
Rate for Payer: Fidelis Essential Plan Aliesa	$85.57
Rate for Payer: Fidelis Essential Plan QHP	$85.57
Rate for Payer: Fidelis Qualified Health Plan	$39.93
Rate for Payer: Hamaspik Choice Inc Medicaid	$38.03
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$38.03
Rate for Payer: Healthfirst Commercial	$57.62
Rate for Payer: Healthfirst Essential Plan	$85.57
Rate for Payer: Healthfirst QHP	$38.03
Rate for Payer: SOMOS CHP/HARP/Medicaid	$38.03
Rate for Payer: SOMOS Essential	$85.57
Rate for Payer: United Healthcare Essential Plan 1&2	$85.57
Rate for Payer: United Healthcare Essential Plan 3&4	$41.83
Rate for Payer: United Healthcare Medicaid	$38.03
Rate for Payer: Wellcare CHP/FHP/Medicaid	$38.03

OUTPATIENT EAPG 00393: LEVEL II BLOOD AND TISSUE TYPING TESTS

Facility

$121.52

Service Code	EAPG 00393
Hospital Charge Code	EAPG 00393
Min. Negotiated Rate	$54.01
Max. Negotiated Rate	$121.52
Rate for Payer: Affinity Essential Plan 1&2	$121.52
Rate for Payer: Affinity Essential Plan 3&4	$121.52
Rate for Payer: Affinity Medicaid/CHP/HARP	$54.01
Rate for Payer: Amida Care Medicaid	$54.01
Rate for Payer: Fidelis CHP/HARP/Medicaid	$54.01
Rate for Payer: Fidelis Essential Plan Aliesa	$121.52
Rate for Payer: Fidelis Essential Plan QHP	$121.52
Rate for Payer: Fidelis Qualified Health Plan	$56.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$54.01
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$54.01
Rate for Payer: Healthfirst Commercial	$81.84
Rate for Payer: Healthfirst Essential Plan	$121.52
Rate for Payer: Healthfirst QHP	$54.01
Rate for Payer: SOMOS CHP/HARP/Medicaid	$54.01
Rate for Payer: SOMOS Essential	$121.52
Rate for Payer: United Healthcare Essential Plan 1&2	$121.52
Rate for Payer: United Healthcare Essential Plan 3&4	$59.41
Rate for Payer: United Healthcare Medicaid	$54.01
Rate for Payer: Wellcare CHP/FHP/Medicaid	$54.01

OUTPATIENT EAPG 00394: LEVEL I IMMUNOLOGY TESTS

Facility

$30.94

Service Code	EAPG 00394
Hospital Charge Code	EAPG 00394
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$30.94
Rate for Payer: Affinity Essential Plan 1&2	$30.94
Rate for Payer: Affinity Essential Plan 3&4	$30.94
Rate for Payer: Affinity Medicaid/CHP/HARP	$13.75
Rate for Payer: Amida Care Medicaid	$13.75
Rate for Payer: Fidelis CHP/HARP/Medicaid	$13.75
Rate for Payer: Fidelis Essential Plan Aliesa	$30.94
Rate for Payer: Fidelis Essential Plan QHP	$30.94
Rate for Payer: Fidelis Qualified Health Plan	$14.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$13.75
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$13.75
Rate for Payer: Healthfirst Commercial	$20.83
Rate for Payer: Healthfirst Essential Plan	$30.94
Rate for Payer: Healthfirst QHP	$13.75
Rate for Payer: SOMOS CHP/HARP/Medicaid	$13.75
Rate for Payer: SOMOS Essential	$30.94
Rate for Payer: United Healthcare Essential Plan 1&2	$30.94
Rate for Payer: United Healthcare Essential Plan 3&4	$15.12
Rate for Payer: United Healthcare Medicaid	$13.75
Rate for Payer: Wellcare CHP/FHP/Medicaid	$13.75

OUTPATIENT EAPG 00395: LEVEL II IMMUNOLOGY TESTS

Facility

$110.68

Service Code	EAPG 00395
Hospital Charge Code	EAPG 00395
Min. Negotiated Rate	$49.19
Max. Negotiated Rate	$110.68
Rate for Payer: Affinity Essential Plan 1&2	$110.68
Rate for Payer: Affinity Essential Plan 3&4	$110.68
Rate for Payer: Affinity Medicaid/CHP/HARP	$49.19
Rate for Payer: Amida Care Medicaid	$49.19
Rate for Payer: Fidelis CHP/HARP/Medicaid	$49.19
Rate for Payer: Fidelis Essential Plan Aliesa	$110.68
Rate for Payer: Fidelis Essential Plan QHP	$110.68
Rate for Payer: Fidelis Qualified Health Plan	$51.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$49.19
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$49.19
Rate for Payer: Healthfirst Commercial	$74.54
Rate for Payer: Healthfirst Essential Plan	$110.68
Rate for Payer: Healthfirst QHP	$49.19
Rate for Payer: SOMOS CHP/HARP/Medicaid	$49.19
Rate for Payer: SOMOS Essential	$110.68
Rate for Payer: United Healthcare Essential Plan 1&2	$110.68
Rate for Payer: United Healthcare Essential Plan 3&4	$54.11
Rate for Payer: United Healthcare Medicaid	$49.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$49.19

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