St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PR EMERGENCY DEPARTMENT VISIT MAY NOT REQ PHYS/QHP

Professional

Both

$50.89

Service Code	HCPCS 99281
Min. Negotiated Rate	$38.17
Max. Negotiated Rate	$38.17
Rate for Payer: Cash Price	$12.95
Rate for Payer: SOMOS CHP/HARP/Medicaid	$38.17
Rate for Payer: SOMOS Essential	$38.17

PR EMERGENCY DEPARTMENT VISIT MODERATE MDM

Professional

Both

$499.00

Service Code	HCPCS 99284
Min. Negotiated Rate	$374.25
Max. Negotiated Rate	$374.25
Rate for Payer: Cash Price	$135.70
Rate for Payer: SOMOS CHP/HARP/Medicaid	$374.25
Rate for Payer: SOMOS Essential	$374.25

PR EMERGENCY DEPARTMENT VISIT STRAIGHTFORWARD MDM

Professional

Both

$174.02

Service Code	HCPCS 99282
Min. Negotiated Rate	$130.52
Max. Negotiated Rate	$130.52
Rate for Payer: Cash Price	$46.94
Rate for Payer: SOMOS CHP/HARP/Medicaid	$130.52
Rate for Payer: SOMOS Essential	$130.52

PR EMG STDS ANAL/URTL SPHNCTR OTH/THN NDL

Professional

Both

$271.08

Service Code	HCPCS 51784
Min. Negotiated Rate	$203.31
Max. Negotiated Rate	$203.31
Rate for Payer: Cash Price	$74.38
Rate for Payer: SOMOS CHP/HARP/Medicaid	$203.31
Rate for Payer: SOMOS Essential	$203.31

PR EMG STDS ANAL/URTL SPHNCTR OTH/THN NDL

Professional

Both

$119.18

Service Code	HCPCS 51784 TC
Min. Negotiated Rate	$89.38
Max. Negotiated Rate	$89.38
Rate for Payer: Cash Price	$33.24
Rate for Payer: SOMOS CHP/HARP/Medicaid	$89.38
Rate for Payer: SOMOS Essential	$89.38

PR EMG STDS ANAL/URTL SPHNCTR OTH/THN NDL

Professional

Both

$151.90

Service Code	HCPCS 51784 26
Min. Negotiated Rate	$113.92
Max. Negotiated Rate	$113.92
Rate for Payer: Cash Price	$41.14
Rate for Payer: SOMOS CHP/HARP/Medicaid	$113.92
Rate for Payer: SOMOS Essential	$113.92

PRE-MIX BONE GRAFT MAT

Facility

$416.67

Service Code	HCPCS C1713
Hospital Charge Code	64903332
Hospital Revenue Code	278
Min. Negotiated Rate	$208.34
Max. Negotiated Rate	$208.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$208.34
Rate for Payer: Hamaspik Choice Inc Medicare	$208.34

PRE-MIX BONE GRAFT MAT

Facility

$416.67

Service Code	HCPCS C1713
Hospital Charge Code	64903332
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$437.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$229.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$250.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$208.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$239.59
Rate for Payer: EmblemHealth Commercial	$208.34
Rate for Payer: Fidelis Medicare Advantage	$437.50
Rate for Payer: Group Health Inc Commercial	$208.34
Rate for Payer: Group Health Inc Medicare	$145.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$208.34
Rate for Payer: Hamaspik Choice Inc Medicare	$208.34
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$270.84

PRENATAL 27-0.8 MG PO TABS [43010]

Facility

$0.04

Service Code	NDC 00904531360
Hospital Charge Code	00904531360
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.02
Rate for Payer: Aetna Government	$0.02
Rate for Payer: Brighton Health Commercial	$0.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.03
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.03
Rate for Payer: Group Health Inc Commercial	$0.02
Rate for Payer: Group Health Inc Medicare	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.02
Rate for Payer: Hamaspik Choice Inc Medicare	$0.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.03

PRENATAL FLOW SHEET

Facility

$10.00

Service Code	HCPCS 0501F
Hospital Charge Code	30304030
Hospital Revenue Code	969
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$8.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$7.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.80
Rate for Payer: Group Health Inc Commercial	$5.00
Rate for Payer: Group Health Inc Medicare	$3.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5.00

PR ENDOCERVICAL CURETTAGE NOT DONE AS PART OF D&C

Professional

Both

$475.58

Service Code	HCPCS 57505
Min. Negotiated Rate	$356.68
Max. Negotiated Rate	$356.68
Rate for Payer: Cash Price	$129.85
Rate for Payer: SOMOS CHP/HARP/Medicaid	$356.68
Rate for Payer: SOMOS Essential	$356.68

PR ENDOLUMINAL BX BILIARY TREE PRQ ANY METH 1/MLT

Professional

Both

$584.33

Service Code	HCPCS 47543
Min. Negotiated Rate	$438.25
Max. Negotiated Rate	$438.25
Rate for Payer: Cash Price	$157.02
Rate for Payer: SOMOS CHP/HARP/Medicaid	$438.25
Rate for Payer: SOMOS Essential	$438.25

PR ENDOLUMINAL BX URTR &/RNL PELVIS NONENDOSCOPIC

Professional

Both

$573.20

Service Code	HCPCS 50606
Min. Negotiated Rate	$429.90
Max. Negotiated Rate	$429.90
Rate for Payer: Cash Price	$154.64
Rate for Payer: SOMOS CHP/HARP/Medicaid	$429.90
Rate for Payer: SOMOS Essential	$429.90

PR ENDOLUMINAL CORONARY IVUS OCT I&R ADDL VESSEL

Professional

Both

$789.36

Service Code	HCPCS 92979
Min. Negotiated Rate	$592.02
Max. Negotiated Rate	$592.02
Rate for Payer: SOMOS CHP/HARP/Medicaid	$592.02
Rate for Payer: SOMOS Essential	$592.02

PR ENDOLUMINAL CORONARY IVUS OCT I&R ADDL VESSEL

Professional

Both

$465.99

Service Code	HCPCS 92979 TC
Min. Negotiated Rate	$349.49
Max. Negotiated Rate	$349.49
Rate for Payer: SOMOS CHP/HARP/Medicaid	$349.49
Rate for Payer: SOMOS Essential	$349.49

PR ENDOLUMINAL CORONARY IVUS OCT I&R ADDL VESSEL

Professional

Both

$323.37

Service Code	HCPCS 92979 26
Min. Negotiated Rate	$242.53
Max. Negotiated Rate	$242.53
Rate for Payer: Cash Price	$85.74
Rate for Payer: SOMOS CHP/HARP/Medicaid	$242.53
Rate for Payer: SOMOS Essential	$242.53

PR ENDOLUMINAL CORONARY IVUS OCT I&R INITIAL VESSEL

Professional

Both

$407.61

Service Code	HCPCS 92978 26
Min. Negotiated Rate	$305.71
Max. Negotiated Rate	$305.71
Rate for Payer: Cash Price	$108.41
Rate for Payer: SOMOS CHP/HARP/Medicaid	$305.71
Rate for Payer: SOMOS Essential	$305.71

PR ENDOLUMINAL CORONARY IVUS OCT I&R INITIAL VESSEL

Professional

Both

$1,328.78

Service Code	HCPCS 92978
Min. Negotiated Rate	$996.58
Max. Negotiated Rate	$996.58
Rate for Payer: SOMOS CHP/HARP/Medicaid	$996.58
Rate for Payer: SOMOS Essential	$996.58

PR ENDOLUMINAL CORONARY IVUS OCT I&R INITIAL VESSEL

Professional

Both

$921.17

Service Code	HCPCS 92978 TC
Min. Negotiated Rate	$690.88
Max. Negotiated Rate	$690.88
Rate for Payer: SOMOS CHP/HARP/Medicaid	$690.88
Rate for Payer: SOMOS Essential	$690.88

PR ENDOLYMPHATIC SAC SHUNT

Professional

Both

$3,993.57

Service Code	HCPCS 69806
Min. Negotiated Rate	$2,995.18
Max. Negotiated Rate	$2,995.18
Rate for Payer: Cash Price	$1,077.94
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,995.18
Rate for Payer: SOMOS Essential	$2,995.18

PR ENDOLYMPHATIC SAC W/O SHUNT

Professional

Both

$4,449.90

Service Code	HCPCS 69805
Min. Negotiated Rate	$3,337.42
Max. Negotiated Rate	$3,337.42
Rate for Payer: Cash Price	$1,203.11
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,337.42
Rate for Payer: SOMOS Essential	$3,337.42

PR ENDOMETRIAL ABLTJ THERMAL W/O HYSTEROSCOPIC GUID

Professional

Both

$1,010.52

Service Code	HCPCS 58353
Min. Negotiated Rate	$757.89
Max. Negotiated Rate	$757.89
Rate for Payer: Cash Price	$271.93
Rate for Payer: SOMOS CHP/HARP/Medicaid	$757.89
Rate for Payer: SOMOS Essential	$757.89

PR ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY

Professional

Both

$172.41

Service Code	HCPCS 58110
Min. Negotiated Rate	$129.31
Max. Negotiated Rate	$129.31
Rate for Payer: Cash Price	$46.77
Rate for Payer: SOMOS CHP/HARP/Medicaid	$129.31
Rate for Payer: SOMOS Essential	$129.31

PR ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX

Professional

Both

$272.55

Service Code	HCPCS 58100
Min. Negotiated Rate	$204.41
Max. Negotiated Rate	$204.41
Rate for Payer: Cash Price	$73.57
Rate for Payer: SOMOS CHP/HARP/Medicaid	$204.41
Rate for Payer: SOMOS Essential	$204.41

PR ENDOMETRIAL CRYOABLATION W/US & ENDOMETRIAL CR

Professional

Both

$1,545.67

Service Code	HCPCS 58356
Min. Negotiated Rate	$1,159.25
Max. Negotiated Rate	$1,159.25
Rate for Payer: Cash Price	$414.96
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1,159.25
Rate for Payer: SOMOS Essential	$1,159.25

Know your out-of-pocket cost for care.

All Charges