St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PROCTOSIGMOIDOSCOPY DX

Facility

$2,313.60

Service Code	HCPCS 45300
Hospital Charge Code	30105536
Hospital Revenue Code	510
Min. Negotiated Rate	$222.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$780.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,056.92
Rate for Payer: Aetna Government	$1,056.92
Rate for Payer: Affinity Essential Plan 1&2	$739.84
Rate for Payer: Affinity Essential Plan 3&4	$739.84
Rate for Payer: Affinity Medicaid/CHP/HARP	$739.84
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cash Price	$1,056.92
Rate for Payer: Cash Price	$1,056.92
Rate for Payer: Cash Price	$1,056.92
Rate for Payer: Cash Price	$1,056.92
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,056.92
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Elderplan Medicare Advantage	$1,056.92
Rate for Payer: Fidelis Essential Plan Aliesa	$898.38
Rate for Payer: Fidelis Essential Plan QHP	$940.66
Rate for Payer: Fidelis Medicare Advantage	$1,056.92
Rate for Payer: Fidelis Qualified Health Plan	$940.66
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,156.80
Rate for Payer: Hamaspik Choice Inc Medicare	$1,056.92
Rate for Payer: Healthfirst Medicare Advantage	$898.38
Rate for Payer: Healthfirst QHP	$1,056.92
Rate for Payer: Humana Medicare	$1,078.06
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$1,056.92
Rate for Payer: Senior Whole Health Medicare Advantage	$1,056.92
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Medicare Advantage	$1,056.92
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,056.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$845.54
Rate for Payer: Wellcare Medicare	$1,004.07

PR OCULAR SURFACE RECONSTRUCTION AMNIOTIC MEMBRANE

Professional

Both

$2,765.42

Service Code	HCPCS 65780
Min. Negotiated Rate	$2,074.06
Max. Negotiated Rate	$2,074.06
Rate for Payer: Cash Price	$673.45
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,074.06
Rate for Payer: SOMOS Essential	$2,074.06

PR OCULAR SURFACE RECONSTRUCTION LIMBAL ALLOGRAFT

Professional

Both

$5,442.64

Service Code	HCPCS 65781
Min. Negotiated Rate	$4,081.98
Max. Negotiated Rate	$4,081.98
Rate for Payer: SOMOS CHP/HARP/Medicaid	$4,081.98
Rate for Payer: SOMOS Essential	$4,081.98

PR OCULAR VEMP TESTING W/I&R

Professional

Both

$171.50

Service Code	HCPCS 92518
Min. Negotiated Rate	$128.62
Max. Negotiated Rate	$128.62
Rate for Payer: Cash Price	$47.53
Rate for Payer: SOMOS CHP/HARP/Medicaid	$128.62
Rate for Payer: SOMOS Essential	$128.62

PRODENSE BONE GRAFT 10CC

Facility

$8,480.00

Service Code	HCPCS C1713
Hospital Charge Code	40203050
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$8,904.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,664.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$5,088.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4,240.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,876.00
Rate for Payer: EmblemHealth Commercial	$4,240.00
Rate for Payer: Fidelis Medicare Advantage	$8,904.00
Rate for Payer: Group Health Inc Commercial	$4,240.00
Rate for Payer: Group Health Inc Medicare	$2,968.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,240.00
Rate for Payer: Hamaspik Choice Inc Medicare	$4,240.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,512.00

PRODENSE BONE GRAFT 10CC

Facility

$8,480.00

Service Code	HCPCS C1713
Hospital Charge Code	40203050
Hospital Revenue Code	278
Min. Negotiated Rate	$4,240.00
Max. Negotiated Rate	$4,240.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,240.00
Rate for Payer: Hamaspik Choice Inc Medicare	$4,240.00

PRODENSE BONE GRAFT 4CC

Facility

$4,200.00

Service Code	HCPCS C1713
Hospital Charge Code	40203051
Hospital Revenue Code	278
Min. Negotiated Rate	$2,100.00
Max. Negotiated Rate	$2,100.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,100.00

PRODENSE BONE GRAFT 4CC

Facility

$4,200.00

Service Code	HCPCS C1713
Hospital Charge Code	40203051
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$4,410.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,310.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$2,520.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,100.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,415.00
Rate for Payer: EmblemHealth Commercial	$2,100.00
Rate for Payer: Fidelis Medicare Advantage	$4,410.00
Rate for Payer: Group Health Inc Commercial	$2,100.00
Rate for Payer: Group Health Inc Medicare	$1,470.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,100.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,730.00

PROF CONSULT (DIAG SERV BY OTHER

Facility

$75.00

Service Code	HCPCS D9310
Hospital Charge Code	42302330
Hospital Revenue Code	361
Min. Negotiated Rate	$26.25
Max. Negotiated Rate	$3,945.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$41.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$58.31
Rate for Payer: Aetna Government	$58.31
Rate for Payer: Affinity Essential Plan 1&2	$88.76
Rate for Payer: Affinity Essential Plan 3&4	$88.76
Rate for Payer: Affinity Medicaid/CHP/HARP	$39.45
Rate for Payer: Amida Care Medicaid	$39.45
Rate for Payer: Brighton Health Commercial	$56.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Fidelis CHP/HARP/Medicaid	$3,945.00
Rate for Payer: Fidelis Essential Plan Aliesa	$39.45
Rate for Payer: Fidelis Essential Plan QHP	$39.45
Rate for Payer: Fidelis Qualified Health Plan	$41.42
Rate for Payer: Group Health Inc Commercial	$37.50
Rate for Payer: Group Health Inc Medicare	$26.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$39.45
Rate for Payer: Hamaspik Choice Inc Medicare	$37.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$39.45
Rate for Payer: Healthfirst Essential Plan	$88.76
Rate for Payer: Healthfirst QHP	$39.45
Rate for Payer: SOMOS CHP/HARP/Medicaid	$39.45
Rate for Payer: SOMOS Essential	$88.76
Rate for Payer: United Healthcare Essential Plan 1&2	$88.76
Rate for Payer: United Healthcare Essential Plan 3&4	$43.40
Rate for Payer: United Healthcare Medicaid	$39.45
Rate for Payer: Wellcare CHP/FHP/Medicaid	$39.45

PROFESSIONAL VISIT-HOSPITAL CALL

Facility

$187.50

Service Code	HCPCS D9420
Hospital Charge Code	42302340
Hospital Revenue Code	361
Min. Negotiated Rate	$65.62
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$103.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$107.23
Rate for Payer: Aetna Government	$107.23
Rate for Payer: Brighton Health Commercial	$140.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Group Health Inc Commercial	$93.75
Rate for Payer: Group Health Inc Medicare	$65.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$93.75
Rate for Payer: Hamaspik Choice Inc Medicare	$93.75

PROFESSIONAL VISIT-HOUSE CALL

Facility

$125.00

Service Code	HCPCS D9410
Hospital Charge Code	42302335
Hospital Revenue Code	361
Min. Negotiated Rate	$43.75
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$68.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$66.39
Rate for Payer: Aetna Government	$66.39
Rate for Payer: Brighton Health Commercial	$93.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Group Health Inc Commercial	$62.50
Rate for Payer: Group Health Inc Medicare	$43.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$62.50
Rate for Payer: Hamaspik Choice Inc Medicare	$62.50

PR OFF BASE OPIOID TX, 60 M

Professional

Both

$1,200.78

Service Code	HCPCS G2087
Min. Negotiated Rate	$900.58
Max. Negotiated Rate	$900.58
Rate for Payer: Cash Price	$431.69
Rate for Payer: SOMOS CHP/HARP/Medicaid	$900.58
Rate for Payer: SOMOS Essential	$900.58

PR OFF BASE OPIOID TX 70MIN

Professional

Both

$1,108.31

Service Code	HCPCS G2086
Min. Negotiated Rate	$831.23
Max. Negotiated Rate	$831.23
Rate for Payer: Cash Price	$446.97
Rate for Payer: SOMOS CHP/HARP/Medicaid	$831.23
Rate for Payer: SOMOS Essential	$831.23

PR OFF BASE OPIOID TX, ADD30

Professional

Both

$139.51

Service Code	HCPCS G2088
Min. Negotiated Rate	$104.63
Max. Negotiated Rate	$104.63
Rate for Payer: Cash Price	$42.33
Rate for Payer: SOMOS CHP/HARP/Medicaid	$104.63
Rate for Payer: SOMOS Essential	$104.63

PR OFFICE CONSULTATION NEW/ESTAB PATIENT 15 MIN

Professional

Both

$104.25

Service Code	HCPCS 99241
Min. Negotiated Rate	$78.19
Max. Negotiated Rate	$78.19
Rate for Payer: SOMOS CHP/HARP/Medicaid	$78.19
Rate for Payer: SOMOS Essential	$78.19

PR OFFICE/OP CONSLTJ NEW/EST PT HIGH MDM 55 MINUTES

Professional

Both

$492.75

Service Code	HCPCS 99245
Min. Negotiated Rate	$125.92
Max. Negotiated Rate	$369.56
Rate for Payer: Amida Care Medicaid	$125.92
Rate for Payer: SOMOS CHP/HARP/Medicaid	$369.56
Rate for Payer: SOMOS Essential	$369.56

PR OFFICE/OP CONSLTJ NEW/EST PT LOW MDM 30 MINUTES

Professional

Both

$273.00

Service Code	HCPCS 99243
Min. Negotiated Rate	$204.75
Max. Negotiated Rate	$204.75
Rate for Payer: SOMOS CHP/HARP/Medicaid	$204.75
Rate for Payer: SOMOS Essential	$204.75

PR OFFICE/OP CONSLTJ NEW/EST PT MOD MDM 40 MINUTES

Professional

Both

$404.25

Service Code	HCPCS 99244
Min. Negotiated Rate	$303.19
Max. Negotiated Rate	$303.19
Rate for Payer: SOMOS CHP/HARP/Medicaid	$303.19
Rate for Payer: SOMOS Essential	$303.19

PR OFFICE/OP CONSLTJ NEW/EST PT SF MDM 20 MINUTES

Professional

Both

$197.25

Service Code	HCPCS 99242
Min. Negotiated Rate	$147.94
Max. Negotiated Rate	$147.94
Rate for Payer: SOMOS CHP/HARP/Medicaid	$147.94
Rate for Payer: SOMOS Essential	$147.94

PR OFFICE/OUTPATIENT ESTABLISHED HIGH MDM 40 MIN

Professional

Both

$582.23

Service Code	HCPCS 99215
Min. Negotiated Rate	$436.67
Max. Negotiated Rate	$562.54
Rate for Payer: Amida Care Medicaid	$562.54
Rate for Payer: Cash Price	$161.31
Rate for Payer: Cash Price	$161.31
Rate for Payer: SOMOS CHP/HARP/Medicaid	$436.67
Rate for Payer: SOMOS Essential	$436.67

PR OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN

Professional

Both

$269.26

Service Code	HCPCS 99213
Min. Negotiated Rate	$134.50
Max. Negotiated Rate	$201.94
Rate for Payer: Amida Care Medicaid	$134.50
Rate for Payer: Cash Price	$73.60
Rate for Payer: Cash Price	$73.60
Rate for Payer: SOMOS CHP/HARP/Medicaid	$201.94
Rate for Payer: SOMOS Essential	$201.94

PR OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30 MIN

Professional

Both

$396.66

Service Code	HCPCS 99214
Min. Negotiated Rate	$287.87
Max. Negotiated Rate	$297.50
Rate for Payer: Amida Care Medicaid	$287.87
Rate for Payer: Cash Price	$108.33
Rate for Payer: Cash Price	$108.33
Rate for Payer: SOMOS CHP/HARP/Medicaid	$297.50
Rate for Payer: SOMOS Essential	$297.50

PR OFFICE/OUTPATIENT ESTABLISHED SF MDM 10 MIN

Professional

Both

$145.78

Service Code	HCPCS 99212
Min. Negotiated Rate	$109.34
Max. Negotiated Rate	$109.34
Rate for Payer: Cash Price	$39.56
Rate for Payer: SOMOS CHP/HARP/Medicaid	$109.34
Rate for Payer: SOMOS Essential	$109.34

PR OFFICE/OUTPATIENT EST PT MAY NOT REQ PHYS/QHP

Professional

Both

$35.35

Service Code	HCPCS 99211
Min. Negotiated Rate	$26.51
Max. Negotiated Rate	$26.51
Rate for Payer: Cash Price	$9.65
Rate for Payer: SOMOS CHP/HARP/Medicaid	$26.51
Rate for Payer: SOMOS Essential	$26.51

PR OFFICE/OUTPATIENT NEW HIGH MDM 60 MINUTES

Professional

Both

$744.56

Service Code	HCPCS 99205
Min. Negotiated Rate	$558.42
Max. Negotiated Rate	$562.54
Rate for Payer: Amida Care Medicaid	$562.54
Rate for Payer: Cash Price	$204.39
Rate for Payer: Cash Price	$204.39
Rate for Payer: SOMOS CHP/HARP/Medicaid	$558.42
Rate for Payer: SOMOS Essential	$558.42

Know your out-of-pocket cost for care.

All Charges