St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PR GENIOPLASTY 2/> SLIDING OSTEOTOMIES

Professional

Both

$3,272.92

Service Code	HCPCS 21122
Min. Negotiated Rate	$2,454.69
Max. Negotiated Rate	$2,454.69
Rate for Payer: Cash Price	$883.47
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,454.69
Rate for Payer: SOMOS Essential	$2,454.69

PR GENIOPLASTY AUGMENTATION

Professional

Both

$2,218.86

Service Code	HCPCS 21120
Min. Negotiated Rate	$1,664.14
Max. Negotiated Rate	$1,664.14
Rate for Payer: Cash Price	$601.15
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1,664.14
Rate for Payer: SOMOS Essential	$1,664.14

PR GENIOPLASTY SLIDING OSTEOTOMY SINGLE PIECE

Professional

Both

$2,225.72

Service Code	HCPCS 21121
Min. Negotiated Rate	$1,669.29
Max. Negotiated Rate	$1,669.29
Rate for Payer: Cash Price	$607.70
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1,669.29
Rate for Payer: SOMOS Essential	$1,669.29

PR GENIOP SLIDING AGMNTJ W/INTERPOSAL BONE GRAFTS

Professional

Both

$3,582.43

Service Code	HCPCS 21123
Min. Negotiated Rate	$2,686.82
Max. Negotiated Rate	$2,686.82
Rate for Payer: Cash Price	$970.67
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,686.82
Rate for Payer: SOMOS Essential	$2,686.82

PR GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/I&R

Professional

Both

$3,178.88

Service Code	HCPCS 91110
Min. Negotiated Rate	$2,384.16
Max. Negotiated Rate	$2,384.16
Rate for Payer: Cash Price	$852.48
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,384.16
Rate for Payer: SOMOS Essential	$2,384.16

PR GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/I&R

Professional

Both

$440.58

Service Code	HCPCS 91110 26
Min. Negotiated Rate	$330.44
Max. Negotiated Rate	$330.44
Rate for Payer: Cash Price	$121.39
Rate for Payer: SOMOS CHP/HARP/Medicaid	$330.44
Rate for Payer: SOMOS Essential	$330.44

PR GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/I&R

Professional

Both

$2,738.30

Service Code	HCPCS 91110 TC
Min. Negotiated Rate	$2,053.72
Max. Negotiated Rate	$2,053.72
Rate for Payer: Cash Price	$731.08
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,053.72
Rate for Payer: SOMOS Essential	$2,053.72

PR GINGIVOPLASTY EACH QUADRANT SPECIFY

Professional

Both

$1,325.31

Service Code	HCPCS 41872
Min. Negotiated Rate	$993.98
Max. Negotiated Rate	$993.98
Rate for Payer: Cash Price	$361.78
Rate for Payer: SOMOS CHP/HARP/Medicaid	$993.98
Rate for Payer: SOMOS Essential	$993.98

PR GI RCNSTJ PREV ESPHG/EXCLUSION W/COLON SM INT

Professional

Both

$12,185.08

Service Code	HCPCS 43361
Min. Negotiated Rate	$9,138.81
Max. Negotiated Rate	$9,138.81
Rate for Payer: Cash Price	$3,245.47
Rate for Payer: SOMOS CHP/HARP/Medicaid	$9,138.81
Rate for Payer: SOMOS Essential	$9,138.81

PR GI RCNSTJ PREV ESPHG/EXCLUSION W/STOMACH

Professional

Both

$10,028.94

Service Code	HCPCS 43360
Min. Negotiated Rate	$7,521.70
Max. Negotiated Rate	$7,521.70
Rate for Payer: Cash Price	$2,670.08
Rate for Payer: SOMOS CHP/HARP/Medicaid	$7,521.70
Rate for Payer: SOMOS Essential	$7,521.70

PR GI TRACT IMAGING INTRALUMINAL COLON I&R

Professional

Both

$3,425.28

Service Code	HCPCS 91113 TC
Min. Negotiated Rate	$2,568.96
Max. Negotiated Rate	$2,568.96
Rate for Payer: Cash Price	$914.03
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,568.96
Rate for Payer: SOMOS Essential	$2,568.96

PR GI TRACT IMAGING INTRALUMINAL COLON I&R

Professional

Both

$3,901.38

Service Code	HCPCS 91113
Min. Negotiated Rate	$2,926.04
Max. Negotiated Rate	$2,926.04
Rate for Payer: Cash Price	$1,045.12
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,926.04
Rate for Payer: SOMOS Essential	$2,926.04

PR GI TRACT IMAGING INTRALUMINAL COLON I&R

Professional

Both

$476.11

Service Code	HCPCS 91113 26
Min. Negotiated Rate	$357.08
Max. Negotiated Rate	$357.08
Rate for Payer: Cash Price	$131.09
Rate for Payer: SOMOS CHP/HARP/Medicaid	$357.08
Rate for Payer: SOMOS Essential	$357.08

PR GI TRANSIT & PRES MEAS WIRELESS CAPSULE W/INTERP

Professional

Both

$417.17

Service Code	HCPCS 91112 26
Min. Negotiated Rate	$312.88
Max. Negotiated Rate	$312.88
Rate for Payer: Cash Price	$114.16
Rate for Payer: SOMOS CHP/HARP/Medicaid	$312.88
Rate for Payer: SOMOS Essential	$312.88

PR GI TRANSIT & PRES MEAS WIRELESS CAPSULE W/INTERP

Professional

Both

$6,662.50

Service Code	HCPCS 91112 TC
Min. Negotiated Rate	$4,996.88
Max. Negotiated Rate	$4,996.88
Rate for Payer: Cash Price	$1,775.33
Rate for Payer: SOMOS CHP/HARP/Medicaid	$4,996.88
Rate for Payer: SOMOS Essential	$4,996.88

PR GI TRANSIT & PRES MEAS WIRELESS CAPSULE W/INTERP

Professional

Both

$7,079.66

Service Code	HCPCS 91112
Min. Negotiated Rate	$5,309.74
Max. Negotiated Rate	$5,309.74
Rate for Payer: Cash Price	$1,889.49
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5,309.74
Rate for Payer: SOMOS Essential	$5,309.74

PR GLAUCOMA SCRN HGH RISK DIREC

Professional

Both

$265.97

Service Code	HCPCS G0117
Min. Negotiated Rate	$199.48
Max. Negotiated Rate	$199.48
Rate for Payer: Cash Price	$73.53
Rate for Payer: SOMOS CHP/HARP/Medicaid	$199.48
Rate for Payer: SOMOS Essential	$199.48

PR GLAUCOMA SCRN HGH RISK DIREC

Professional

Both

$177.84

Service Code	HCPCS G0118
Min. Negotiated Rate	$133.38
Max. Negotiated Rate	$133.38
Rate for Payer: Cash Price	$48.99
Rate for Payer: SOMOS CHP/HARP/Medicaid	$133.38
Rate for Payer: SOMOS Essential	$133.38

PR GLOSSECTOMY HEMIGLOSSECTOMY

Professional

Both

$5,664.16

Service Code	HCPCS 41130
Min. Negotiated Rate	$4,248.12
Max. Negotiated Rate	$4,248.12
Rate for Payer: Cash Price	$1,525.58
Rate for Payer: SOMOS CHP/HARP/Medicaid	$4,248.12
Rate for Payer: SOMOS Essential	$4,248.12

PR GLOSSECTOMY <ONE-HALF TONGUE

Professional

Both

$4,581.68

Service Code	HCPCS 41120
Min. Negotiated Rate	$3,436.26
Max. Negotiated Rate	$3,436.26
Rate for Payer: Cash Price	$1,234.29
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,436.26
Rate for Payer: SOMOS Essential	$3,436.26

PR GLOSSECTOMY PRTL W/UNI RADICAL NECK DSJ

Professional

Both

$9,291.00

Service Code	HCPCS 41135
Min. Negotiated Rate	$6,968.25
Max. Negotiated Rate	$6,968.25
Rate for Payer: Cash Price	$2,509.02
Rate for Payer: SOMOS CHP/HARP/Medicaid	$6,968.25
Rate for Payer: SOMOS Essential	$6,968.25

PR GLSSC COMPL/TOT W/WOTRACHS W/O RAD NECK DSJ

Professional

Both

$9,380.88

Service Code	HCPCS 41140
Min. Negotiated Rate	$7,035.66
Max. Negotiated Rate	$7,035.66
Rate for Payer: Cash Price	$2,527.28
Rate for Payer: SOMOS CHP/HARP/Medicaid	$7,035.66
Rate for Payer: SOMOS Essential	$7,035.66

PR GLSSC COMPL/TOT W/WO TRACHS W/UNI RAD NECK DSJ

Professional

Both

$11,813.13

Service Code	HCPCS 41145
Min. Negotiated Rate	$8,859.85
Max. Negotiated Rate	$8,859.85
Rate for Payer: Cash Price	$3,180.98
Rate for Payer: SOMOS CHP/HARP/Medicaid	$8,859.85
Rate for Payer: SOMOS Essential	$8,859.85

PR GLSSC COMPOSIT RESCJ FLOOR SUPRAHYOID NCK DSJ

Professional

Both

$10,232.08

Service Code	HCPCS 41153
Min. Negotiated Rate	$7,674.06
Max. Negotiated Rate	$7,674.06
Rate for Payer: Cash Price	$2,769.53
Rate for Payer: SOMOS CHP/HARP/Medicaid	$7,674.06
Rate for Payer: SOMOS Essential	$7,674.06

PR GLSSC COMPOSIT RESCJ FLR MNDBLR RESCJ & RAD NECK

Professional

Both

$12,818.09

Service Code	HCPCS 41155
Min. Negotiated Rate	$9,613.57
Max. Negotiated Rate	$9,613.57
Rate for Payer: Cash Price	$3,445.31
Rate for Payer: SOMOS CHP/HARP/Medicaid	$9,613.57
Rate for Payer: SOMOS Essential	$9,613.57

Know your out-of-pocket cost for care.

All Charges