St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PR ISCHEMIC LIMB XERS TST SPEC ACQUISJ METAB

Professional

Both

$344.86

Service Code	HCPCS 95875 TC
Min. Negotiated Rate	$258.64
Max. Negotiated Rate	$258.64
Rate for Payer: Cash Price	$76.46
Rate for Payer: SOMOS CHP/HARP/Medicaid	$258.64
Rate for Payer: SOMOS Essential	$258.64

PRISMASOL BGK 0/2.5

Facility

$106.60

Service Code	HCPCS J3490
Hospital Charge Code	41640373
Hospital Revenue Code	636
Min. Negotiated Rate	$53.30
Max. Negotiated Rate	$53.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$53.30
Rate for Payer: Hamaspik Choice Inc Medicare	$53.30

PRISMASOL BGK 0/2.5

Facility

$106.60

Service Code	HCPCS J3490
Hospital Charge Code	41650373
Hospital Revenue Code	636
Min. Negotiated Rate	$53.30
Max. Negotiated Rate	$53.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$53.30
Rate for Payer: Hamaspik Choice Inc Medicare	$53.30

PRISMASOL BGK 0/2.5

Facility

$106.60

Service Code	HCPCS J3490
Hospital Charge Code	41640373
Hospital Revenue Code	636
Min. Negotiated Rate	$37.31
Max. Negotiated Rate	$69.29
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$58.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$53.30
Rate for Payer: Aetna Government	$53.30
Rate for Payer: Brighton Health Commercial	$63.96
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$53.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$61.30
Rate for Payer: Group Health Inc Commercial	$53.30
Rate for Payer: Group Health Inc Medicare	$37.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$53.30
Rate for Payer: Hamaspik Choice Inc Medicare	$53.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$69.29

PRISMASOL BGK 0/2.5

Facility

$106.60

Service Code	HCPCS J3490
Hospital Charge Code	41650373
Hospital Revenue Code	636
Min. Negotiated Rate	$37.31
Max. Negotiated Rate	$69.29
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$58.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$53.30
Rate for Payer: Aetna Government	$53.30
Rate for Payer: Brighton Health Commercial	$63.96
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$53.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$61.30
Rate for Payer: Group Health Inc Commercial	$53.30
Rate for Payer: Group Health Inc Medicare	$37.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$53.30
Rate for Payer: Hamaspik Choice Inc Medicare	$53.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$69.29

PRISMASOL BGK 0/2.5 32-2.5 MEQ/L APHERESIS SOLN [181359]

Facility

$0.02

Service Code	NDC 24571010806
Hospital Charge Code	24571010806
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

PR IV DOP VEL&/OR PRESS C/FLO RSRV MEAS 1ST VSL

Professional

Both

$921.17

Service Code	HCPCS 93571 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 IV DOP VEL&/OR PRESS C/FLO RSRV MEAS 1ST VSL

Professional

Both

$1,231.41

Service Code	HCPCS 93571
Min. Negotiated Rate	$923.56
Max. Negotiated Rate	$923.56
Rate for Payer: SOMOS CHP/HARP/Medicaid	$923.56
Rate for Payer: SOMOS Essential	$923.56

PR IV DOP VEL&/OR PRESS C/FLO RSRV MEAS 1ST VSL

Professional

Both

$310.24

Service Code	HCPCS 93571 26
Min. Negotiated Rate	$232.68
Max. Negotiated Rate	$232.68
Rate for Payer: Cash Price	$82.24
Rate for Payer: SOMOS CHP/HARP/Medicaid	$232.68
Rate for Payer: SOMOS Essential	$232.68

PR IV DOP VEL&/OR PRESS C/FLO RSRV MEAS ADDL VSL

Professional

Both

$377.13

Service Code	HCPCS 93572 TC
Min. Negotiated Rate	$282.85
Max. Negotiated Rate	$282.85
Rate for Payer: SOMOS CHP/HARP/Medicaid	$282.85
Rate for Payer: SOMOS Essential	$282.85

PR IV DOP VEL&/OR PRESS C/FLO RSRV MEAS ADDL VSL

Professional

Both

$603.23

Service Code	HCPCS 93572
Min. Negotiated Rate	$452.42
Max. Negotiated Rate	$452.42
Rate for Payer: SOMOS CHP/HARP/Medicaid	$452.42
Rate for Payer: SOMOS Essential	$452.42

PR IV DOP VEL&/OR PRESS C/FLO RSRV MEAS ADDL VSL

Professional

Both

$226.10

Service Code	HCPCS 93572 26
Min. Negotiated Rate	$169.58
Max. Negotiated Rate	$169.58
Rate for Payer: Cash Price	$60.12
Rate for Payer: SOMOS CHP/HARP/Medicaid	$169.58
Rate for Payer: SOMOS Essential	$169.58

PR IV INFUSION HYDRATION EACH ADDITIONAL HOUR

Professional

Both

$54.25

Service Code	HCPCS 96361
Min. Negotiated Rate	$40.69
Max. Negotiated Rate	$40.69
Rate for Payer: Cash Price	$14.37
Rate for Payer: SOMOS CHP/HARP/Medicaid	$40.69
Rate for Payer: SOMOS Essential	$40.69

PR IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR

Professional

Both

$137.59

Service Code	HCPCS 96360
Min. Negotiated Rate	$103.19
Max. Negotiated Rate	$103.19
Rate for Payer: Cash Price	$37.60
Rate for Payer: SOMOS CHP/HARP/Medicaid	$103.19
Rate for Payer: SOMOS Essential	$103.19

PR IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR

Professional

Both

$275.87

Service Code	HCPCS 96365
Min. Negotiated Rate	$206.90
Max. Negotiated Rate	$206.90
Rate for Payer: Cash Price	$73.87
Rate for Payer: SOMOS CHP/HARP/Medicaid	$206.90
Rate for Payer: SOMOS Essential	$206.90

PR IV INFUSION THERAPY PROPHYLAXIS/DX EA HOUR

Professional

Both

$85.65

Service Code	HCPCS 96366
Min. Negotiated Rate	$64.24
Max. Negotiated Rate	$64.24
Rate for Payer: Cash Price	$23.41
Rate for Payer: SOMOS CHP/HARP/Medicaid	$64.24
Rate for Payer: SOMOS Essential	$64.24

PR IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR

Professional

Both

$121.42

Service Code	HCPCS 96367
Min. Negotiated Rate	$91.06
Max. Negotiated Rate	$91.06
Rate for Payer: Cash Price	$32.79
Rate for Payer: SOMOS CHP/HARP/Medicaid	$91.06
Rate for Payer: SOMOS Essential	$91.06

PR IV INJECTION TEST VASCULAR FLOW FLAP/GRAFT

Professional

Both

$464.94

Service Code	HCPCS 15860
Min. Negotiated Rate	$348.70
Max. Negotiated Rate	$348.70
Rate for Payer: Cash Price	$124.16
Rate for Payer: SOMOS CHP/HARP/Medicaid	$348.70
Rate for Payer: SOMOS Essential	$348.70

PR IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS

Professional

Both

$82.95

Service Code	HCPCS 96368
Min. Negotiated Rate	$62.21
Max. Negotiated Rate	$62.21
Rate for Payer: Cash Price	$22.66
Rate for Payer: SOMOS CHP/HARP/Medicaid	$62.21
Rate for Payer: SOMOS Essential	$62.21

PR JOINT REPLAC MOD HOME VISIT

Professional

Both

$194.64

Service Code	HCPCS G9490
Min. Negotiated Rate	$145.98
Max. Negotiated Rate	$145.98
Rate for Payer: Cash Price	$56.09
Rate for Payer: SOMOS CHP/HARP/Medicaid	$145.98
Rate for Payer: SOMOS Essential	$145.98

PR KERATOPLASTY ANTERIOR LAMELLAR

Professional

Both

$4,713.98

Service Code	HCPCS 65710
Min. Negotiated Rate	$3,535.48
Max. Negotiated Rate	$3,535.48
Rate for Payer: Cash Price	$1,292.27
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,535.48
Rate for Payer: SOMOS Essential	$3,535.48

PR KERATOPLASTY ENDOTHELIAL

Professional

Both

$4,833.99

Service Code	HCPCS 65756
Min. Negotiated Rate	$3,625.49
Max. Negotiated Rate	$3,625.49
Rate for Payer: Cash Price	$1,331.94
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,625.49
Rate for Payer: SOMOS Essential	$3,625.49

PR KERATOPLASTY PENETRAING APHAKIA

Professional

Both

$5,190.96

Service Code	HCPCS 65750
Min. Negotiated Rate	$3,893.22
Max. Negotiated Rate	$3,893.22
Rate for Payer: Cash Price	$1,425.35
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,893.22
Rate for Payer: SOMOS Essential	$3,893.22

PR KERATOPLASTY PENETRATING PSEUDOPHAKIA

Professional

Both

$5,174.33

Service Code	HCPCS 65755
Min. Negotiated Rate	$3,880.75
Max. Negotiated Rate	$3,880.75
Rate for Payer: Cash Price	$1,421.75
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,880.75
Rate for Payer: SOMOS Essential	$3,880.75

PR KERATOPLASTY PENTRG EXCEPT APHAKIA/PSEUDOPHAKIA

Professional

Both

$5,165.48

Service Code	HCPCS 65730
Min. Negotiated Rate	$3,874.11
Max. Negotiated Rate	$3,874.11
Rate for Payer: Cash Price	$1,418.83
Rate for Payer: SOMOS CHP/HARP/Medicaid	$3,874.11
Rate for Payer: SOMOS Essential	$3,874.11

Know your out-of-pocket cost for care.

All Charges