St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PR FREE SKIN FLAP W/MICROVASCULAR ANASTOMOSIS

Professional

Both

$9,799.86

Service Code	HCPCS 15757
Min. Negotiated Rate	$7,349.90
Max. Negotiated Rate	$7,349.90
Rate for Payer: Cash Price	$2,635.56
Rate for Payer: SOMOS CHP/HARP/Medicaid	$7,349.90
Rate for Payer: SOMOS Essential	$7,349.90

PR FRENOPLASTY SURG REVJ FRENUM EG W/Z-PLASTY

Professional

Both

$1,087.77

Service Code	HCPCS 41520
Min. Negotiated Rate	$815.83
Max. Negotiated Rate	$815.83
Rate for Payer: Cash Price	$295.82
Rate for Payer: SOMOS CHP/HARP/Medicaid	$815.83
Rate for Payer: SOMOS Essential	$815.83

PR FRENULOTOMY PENIS

Professional

Both

$818.55

Service Code	HCPCS 54164
Min. Negotiated Rate	$613.91
Max. Negotiated Rate	$613.91
Rate for Payer: Cash Price	$226.33
Rate for Payer: SOMOS CHP/HARP/Medicaid	$613.91
Rate for Payer: SOMOS Essential	$613.91

PR FRMJ DIRECT/TUBED PEDICLE W/WO TRANSFER TRUNK

Professional

Both

$3,203.69

Service Code	HCPCS 15570
Min. Negotiated Rate	$2,402.77
Max. Negotiated Rate	$2,402.77
Rate for Payer: Cash Price	$861.71
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,402.77
Rate for Payer: SOMOS Essential	$2,402.77

PR FRMJ DIRECT/TUBED PEDICLE W/WOTR E/N/E/L/NTRORAL

Professional

Both

$2,746.45

Service Code	HCPCS 15576
Min. Negotiated Rate	$2,059.84
Max. Negotiated Rate	$2,059.84
Rate for Payer: Cash Price	$748.42
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,059.84
Rate for Payer: SOMOS Essential	$2,059.84

PR FRMJ DIRECT/TUBE PEDICLE W/WO TR SCALP ARMS/LEGS

Professional

Both

$3,199.77

Service Code	HCPCS 15572
Min. Negotiated Rate	$2,399.83
Max. Negotiated Rate	$2,399.83
Rate for Payer: Cash Price	$867.28
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,399.83
Rate for Payer: SOMOS Essential	$2,399.83

PR FRMJ DIR/TUBE PEDCL W/WOTR FH/CH/CH/M/N/AX/G/H/F

Professional

Both

$3,160.82

Service Code	HCPCS 15574
Min. Negotiated Rate	$2,370.62
Max. Negotiated Rate	$2,370.62
Rate for Payer: Cash Price	$865.06
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,370.62
Rate for Payer: SOMOS Essential	$2,370.62

PR FR OSTQ FLAP W/MVASC ANAST GRT TOE W/WEB SPACE

Professional

Both

$13,197.17

Service Code	HCPCS 20973
Min. Negotiated Rate	$9,897.88
Max. Negotiated Rate	$9,897.88
Rate for Payer: Cash Price	$3,546.54
Rate for Payer: SOMOS CHP/HARP/Medicaid	$9,897.88
Rate for Payer: SOMOS Essential	$9,897.88

PR FSTLJ SCLERA GLAUCOMA THERMOCAUT IRRIDEC

Professional

Both

$3,622.29

Service Code	HCPCS 66155
Min. Negotiated Rate	$2,716.72
Max. Negotiated Rate	$2,716.72
Rate for Payer: Cash Price	$998.92
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,716.72
Rate for Payer: SOMOS Essential	$2,716.72

PR FSTLJ SCLERA GLAUCOMA TRABECULECT AB EXTERNO

Professional

Both

$4,504.15

Service Code	HCPCS 66170
Min. Negotiated Rate	$3,378.11
Max. Negotiated Rate	$3,378.11
Rate for Payer: Cash Price	$1,242.82
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,378.11
Rate for Payer: SOMOS Essential	$3,378.11

PR FSTLJ SCLERA GLAUCOMA TREPHIN W/IRIDECTOMY

Professional

Both

$3,624.99

Service Code	HCPCS 66150
Min. Negotiated Rate	$2,718.74
Max. Negotiated Rate	$2,718.74
Rate for Payer: Cash Price	$999.27
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,718.74
Rate for Payer: SOMOS Essential	$2,718.74

PR FSTLJ SCLERA GLC TRBEC AB EXTERNO SCARRING

Professional

Both

$4,922.09

Service Code	HCPCS 66172
Min. Negotiated Rate	$3,691.57
Max. Negotiated Rate	$3,691.57
Rate for Payer: Cash Price	$1,358.35
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,691.57
Rate for Payer: SOMOS Essential	$3,691.57

PR FSTLJ SCLERA SCLERECTOMY PUNCH/SCISSORS IRIDECT

Professional

Both

$4,068.61

Service Code	HCPCS 66160
Min. Negotiated Rate	$3,051.46
Max. Negotiated Rate	$3,051.46
Rate for Payer: Cash Price	$1,120.90
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,051.46
Rate for Payer: SOMOS Essential	$3,051.46

PR FTH/GF FR W/DIR CLSR F/C/C/M/N/AX/G/H/F 20SQCM/<

Professional

Both

$3,386.29

Service Code	HCPCS 15240
Min. Negotiated Rate	$2,539.72
Max. Negotiated Rate	$2,539.72
Rate for Payer: Cash Price	$927.40
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,539.72
Rate for Payer: SOMOS Essential	$2,539.72

PR FTH/GFT FREE W/DIR CLSR N/E/E/L EA ADDL 20 SQ CM

Professional

Both

$576.87

Service Code	HCPCS 15261
Min. Negotiated Rate	$432.65
Max. Negotiated Rate	$432.65
Rate for Payer: Cash Price	$155.78
Rate for Payer: SOMOS CHP/HARP/Medicaid	$432.65
Rate for Payer: SOMOS Essential	$432.65

PR FTH/GFT FREE W/DIRECT CLOSURE N/E/E/L 20 SQ CM/<

Professional

Both

$3,568.22

Service Code	HCPCS 15260
Min. Negotiated Rate	$2,676.16
Max. Negotiated Rate	$2,676.16
Rate for Payer: Cash Price	$976.99
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,676.16
Rate for Payer: SOMOS Essential	$2,676.16

PR FTH/GFT FREE W/DIRECT CLOSURE S/A/L 20 SQ CM/<

Professional

Both

$2,604.70

Service Code	HCPCS 15220
Min. Negotiated Rate	$1,953.52
Max. Negotiated Rate	$1,953.52
Rate for Payer: Cash Price	$712.58
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1,953.52
Rate for Payer: SOMOS Essential	$1,953.52

PR FTH/GFT FREE W/DIRECT CLOSURE TRUNK 20 SQ CM/<

Professional

Both

$2,920.54

Service Code	HCPCS 15200
Min. Negotiated Rate	$2,190.40
Max. Negotiated Rate	$2,190.40
Rate for Payer: Cash Price	$793.65
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,190.40
Rate for Payer: SOMOS Essential	$2,190.40

PR FTH/GFT FR W/DIR CLSR S/A/L EA ADDL 20 SQ CM/<

Professional

Both

$297.22

Service Code	HCPCS 15221
Min. Negotiated Rate	$222.92
Max. Negotiated Rate	$222.92
Rate for Payer: Cash Price	$80.18
Rate for Payer: SOMOS CHP/HARP/Medicaid	$222.92
Rate for Payer: SOMOS Essential	$222.92

PR FTH/GFT FR W/DIR CLSR TRNK EA ADDL 20 SQ CM

Professional

Both

$334.36

Service Code	HCPCS 15201
Min. Negotiated Rate	$250.77
Max. Negotiated Rate	$250.77
Rate for Payer: Cash Price	$89.18
Rate for Payer: SOMOS CHP/HARP/Medicaid	$250.77
Rate for Payer: SOMOS Essential	$250.77

PR FTH/GT FR W/DIR CLSR F/C/C/M/N/AX/G/H/F EA ADDL

Professional

Both

$451.75

Service Code	HCPCS 15241
Min. Negotiated Rate	$338.81
Max. Negotiated Rate	$338.81
Rate for Payer: Cash Price	$123.95
Rate for Payer: SOMOS CHP/HARP/Medicaid	$338.81
Rate for Payer: SOMOS Essential	$338.81

PRFTNSTRL HIOPUCLR SFTP110MM4-1/3

Facility

$102.62

Service Code	HCPCS A6154
Hospital Charge Code	40005173
Hospital Revenue Code	272
Min. Negotiated Rate	$8.75
Max. Negotiated Rate	$82.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$56.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$8.75
Rate for Payer: Aetna Government	$8.75
Rate for Payer: Brighton Health Commercial	$76.96
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$82.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$69.78
Rate for Payer: Group Health Inc Commercial	$51.31
Rate for Payer: Group Health Inc Medicare	$35.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$51.31
Rate for Payer: Hamaspik Choice Inc Medicare	$51.31

PRFTNSTRL HIOPUCLR SFTP70MM2-3/4

Facility

$93.28

Service Code	HCPCS A6154
Hospital Charge Code	40005174
Hospital Revenue Code	272
Min. Negotiated Rate	$8.75
Max. Negotiated Rate	$74.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$51.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$8.75
Rate for Payer: Aetna Government	$8.75
Rate for Payer: Brighton Health Commercial	$69.96
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$74.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$63.43
Rate for Payer: Group Health Inc Commercial	$46.64
Rate for Payer: Group Health Inc Medicare	$32.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$46.64
Rate for Payer: Hamaspik Choice Inc Medicare	$46.64

PR FULL FIELD ELECTRORETINOGRAPHY W/I&R

Professional

Both

$534.52

Service Code	HCPCS 92273
Min. Negotiated Rate	$400.89
Max. Negotiated Rate	$400.89
Rate for Payer: Cash Price	$146.18
Rate for Payer: SOMOS CHP/HARP/Medicaid	$400.89
Rate for Payer: SOMOS Essential	$400.89

PR FULL FIELD ELECTRORETINOGRAPHY W/I&R

Professional

Both

$392.18

Service Code	HCPCS 92273 TC
Min. Negotiated Rate	$294.14
Max. Negotiated Rate	$294.14
Rate for Payer: Cash Price	$107.34
Rate for Payer: SOMOS CHP/HARP/Medicaid	$294.14
Rate for Payer: SOMOS Essential	$294.14

Know your out-of-pocket cost for care.

All Charges