St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PR GLSSC COMPOSIT W/RESCJ FLOOR & MANDIBULAR RESCJ

Professional

Both

$9,443.67

Service Code	HCPCS 41150
Min. Negotiated Rate	$7,082.75
Max. Negotiated Rate	$7,082.75
Rate for Payer: Cash Price	$2,547.12
Rate for Payer: SOMOS CHP/HARP/Medicaid	$7,082.75
Rate for Payer: SOMOS Essential	$7,082.75

PR GONIOSCOPY SEPARATE PROCEDURE

Professional

Both

$80.71

Service Code	HCPCS 92020
Min. Negotiated Rate	$60.53
Max. Negotiated Rate	$60.53
Rate for Payer: Cash Price	$22.17
Rate for Payer: SOMOS CHP/HARP/Medicaid	$60.53
Rate for Payer: SOMOS Essential	$60.53

PR GONIOTOMY

Professional

Both

$3,431.09

Service Code	HCPCS 65820
Min. Negotiated Rate	$2,573.32
Max. Negotiated Rate	$2,573.32
Rate for Payer: Cash Price	$941.16
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,573.32
Rate for Payer: SOMOS Essential	$2,573.32

PR GRAFT BONE MANDIBLE

Professional

Both

$3,289.41

Service Code	HCPCS 21215
Min. Negotiated Rate	$2,467.06
Max. Negotiated Rate	$2,467.06
Rate for Payer: Cash Price	$902.60
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,467.06
Rate for Payer: SOMOS Essential	$2,467.06

PR GRAFT BONE NASAL/MAXILLARY/MALAR AREAS

Professional

Both

$3,170.72

Service Code	HCPCS 21210
Min. Negotiated Rate	$2,378.04
Max. Negotiated Rate	$2,378.04
Rate for Payer: Cash Price	$868.85
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,378.04
Rate for Payer: SOMOS Essential	$2,378.04

PR GRAFT COMPOSITE W/PRIMARY CLOSURE DONOR AREA

Professional

Both

$2,991.66

Service Code	HCPCS 15760
Min. Negotiated Rate	$2,243.74
Max. Negotiated Rate	$2,243.74
Rate for Payer: Cash Price	$812.28
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,243.74
Rate for Payer: SOMOS Essential	$2,243.74

PR GRAFT DERMA-FAT-FASCIA

Professional

Both

$2,900.21

Service Code	HCPCS 15770
Min. Negotiated Rate	$2,175.16
Max. Negotiated Rate	$2,175.16
Rate for Payer: Cash Price	$792.19
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,175.16
Rate for Payer: SOMOS Essential	$2,175.16

PR GRAFT EAR CRTLG AUTOGENOUS NOSE/EAR

Professional

Both

$2,446.08

Service Code	HCPCS 21235
Min. Negotiated Rate	$1,834.56
Max. Negotiated Rate	$1,834.56
Rate for Payer: Cash Price	$668.94
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1,834.56
Rate for Payer: SOMOS Essential	$1,834.56

PR GRAFT FACIAL NERVE PARALYSIS FREE FASCIAL GRAFT

Professional

Both

$4,372.80

Service Code	HCPCS 15840
Min. Negotiated Rate	$3,279.60
Max. Negotiated Rate	$3,279.60
Rate for Payer: Cash Price	$1,181.47
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,279.60
Rate for Payer: SOMOS Essential	$3,279.60

PR GRAFT FACIAL NERVE PARALYSIS FREE MUSCLE GRAFT

Professional

Both

$7,761.60

Service Code	HCPCS 15841
Min. Negotiated Rate	$5,821.20
Max. Negotiated Rate	$5,821.20
Rate for Payer: Cash Price	$2,090.79
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5,821.20
Rate for Payer: SOMOS Essential	$5,821.20

PR GRAFTING OF AUTOLOGOUS FAT BY LIPO 25 CC OR LESS

Professional

Both

$2,175.04

Service Code	HCPCS 15773
Min. Negotiated Rate	$1,631.28
Max. Negotiated Rate	$1,631.28
Rate for Payer: Cash Price	$590.76
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1,631.28
Rate for Payer: SOMOS Essential	$1,631.28

PR GRAFTING OF AUTOLOGOUS FAT BY LIPO 50 CC OR LESS

Professional

Both

$2,224.11

Service Code	HCPCS 15771
Min. Negotiated Rate	$1,668.08
Max. Negotiated Rate	$1,668.08
Rate for Payer: Cash Price	$606.04
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1,668.08
Rate for Payer: SOMOS Essential	$1,668.08

PR GRAFTING OF AUTOLOGOUS FAT BY LIPO EA ADDL 25 CC

Professional

Both

$627.80

Service Code	HCPCS 15774
Min. Negotiated Rate	$470.85
Max. Negotiated Rate	$470.85
Rate for Payer: Cash Price	$166.98
Rate for Payer: SOMOS CHP/HARP/Medicaid	$470.85
Rate for Payer: SOMOS Essential	$470.85

PR GRAFTING OF AUTOLOGOUS FAT BY LIPO EA ADDL 50 CC

Professional

Both

$643.37

Service Code	HCPCS 15772
Min. Negotiated Rate	$482.53
Max. Negotiated Rate	$482.53
Rate for Payer: Cash Price	$172.94
Rate for Payer: SOMOS CHP/HARP/Medicaid	$482.53
Rate for Payer: SOMOS Essential	$482.53

PR GRAFTING OF AUTOLOGOUS SOFT TISS BY DIRECT EXC

Professional

Both

$2,108.61

Service Code	HCPCS 15769
Min. Negotiated Rate	$1,581.46
Max. Negotiated Rate	$1,581.46
Rate for Payer: Cash Price	$568.77
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1,581.46
Rate for Payer: SOMOS Essential	$1,581.46

PR GRAFT RIB CRTLG AUTOGENOUS FACE/CHIN/NOSE/EAR

Professional

Both

$3,240.86

Service Code	HCPCS 21230
Min. Negotiated Rate	$2,430.64
Max. Negotiated Rate	$2,430.64
Rate for Payer: Cash Price	$876.46
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,430.64
Rate for Payer: SOMOS Essential	$2,430.64

PR GRAFT THIERSCH RCT INCONTINENCE &/PROLAPSE

Professional

Both

$2,805.92

Service Code	HCPCS 46753
Min. Negotiated Rate	$2,104.44
Max. Negotiated Rate	$2,104.44
Rate for Payer: Cash Price	$748.96
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,104.44
Rate for Payer: SOMOS Essential	$2,104.44

PR GRF FACIAL NERVE PARALYSIS REGIONAL MUSCLE TR

Professional

Both

$4,630.12

Service Code	HCPCS 15845
Min. Negotiated Rate	$3,472.59
Max. Negotiated Rate	$3,472.59
Rate for Payer: Cash Price	$1,253.41
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,472.59
Rate for Payer: SOMOS Essential	$3,472.59

PR GRF FACIAL NRV PALYSS FR MUSCLE FLAP MICROSURG

Professional

Both

$11,764.20

Service Code	HCPCS 15842
Min. Negotiated Rate	$8,823.15
Max. Negotiated Rate	$8,823.15
Rate for Payer: Cash Price	$3,163.30
Rate for Payer: SOMOS CHP/HARP/Medicaid	$8,823.15
Rate for Payer: SOMOS Essential	$8,823.15

PR GROUP BEHAVE COUNS 2-10

Professional

Both

$45.92

Service Code	HCPCS G0473
Min. Negotiated Rate	$34.44
Max. Negotiated Rate	$34.44
Rate for Payer: Cash Price	$12.58
Rate for Payer: SOMOS CHP/HARP/Medicaid	$34.44
Rate for Payer: SOMOS Essential	$34.44

PR GROUP MNT 2 OR MORE 30 MINS

Professional

Both

$62.79

Service Code	HCPCS G0271
Min. Negotiated Rate	$47.09
Max. Negotiated Rate	$47.09
Rate for Payer: Cash Price	$17.20
Rate for Payer: SOMOS CHP/HARP/Medicaid	$47.09
Rate for Payer: SOMOS Essential	$47.09

PR GROUP PSYCHOTHERAPY

Professional

Both

$90.86

Service Code	HCPCS 90853
Min. Negotiated Rate	$68.14
Max. Negotiated Rate	$68.14
Rate for Payer: Cash Price	$26.02
Rate for Payer: SOMOS CHP/HARP/Medicaid	$68.14
Rate for Payer: SOMOS Essential	$68.14

PR GSTRCT PRTL DSTL W/FRMJ INTSTINAL POUCH

Professional

Both

$9,609.46

Service Code	HCPCS 43634
Min. Negotiated Rate	$7,207.10
Max. Negotiated Rate	$7,207.10
Rate for Payer: Cash Price	$2,556.13
Rate for Payer: SOMOS CHP/HARP/Medicaid	$7,207.10
Rate for Payer: SOMOS Essential	$7,207.10

PR GSTRCT PRTL DSTL W/GASTRODUODENOSTOMY

Professional

Both

$6,515.81

Service Code	HCPCS 43631
Min. Negotiated Rate	$4,886.86
Max. Negotiated Rate	$4,886.86
Rate for Payer: Cash Price	$1,741.27
Rate for Payer: SOMOS CHP/HARP/Medicaid	$4,886.86
Rate for Payer: SOMOS Essential	$4,886.86

PR GSTRCT PRTL DSTL W/GASTROJEJUNOSTOMY

Professional

Both

$9,183.69

Service Code	HCPCS 43632
Min. Negotiated Rate	$6,887.77
Max. Negotiated Rate	$6,887.77
Rate for Payer: Cash Price	$2,443.18
Rate for Payer: SOMOS CHP/HARP/Medicaid	$6,887.77
Rate for Payer: SOMOS Essential	$6,887.77

Know your out-of-pocket cost for care.

All Charges