St. Barnabas Hospital

All Charges

Charge

Type

Price

ZZ BALLOON/8-4/120/XXL

Facility IP

$722.93

Service Code	HCPCS C1725
Hospital Charge Code	41569132
Hospital Revenue Code	278
Min. Negotiated Rate	$361.46
Max. Negotiated Rate	$361.46
Rate for Payer: Hamaspik Choice Inc Medicaid	$361.46
Rate for Payer: Hamaspik Choice Inc Medicare	$361.46

ZZ BALLOON/8-4/120/XXL

Facility OP

$722.93

Service Code	HCPCS C1725
Hospital Charge Code	41569132
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$759.08
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$397.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.85
Rate for Payer: Aetna Government	$44.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$361.46
Rate for Payer: Cigna LocalPlus Benefit Plan	$415.68
Rate for Payer: Fidelis Medicare Advantage	$759.08
Rate for Payer: Group Health Inc Commercial	$361.46
Rate for Payer: Group Health Inc Medicare	$253.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$361.46
Rate for Payer: Hamaspik Choice Inc Medicare	$361.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$469.90

ZZ BALLOON/BLUEMAX/10-4-75CM

Facility IP

$550.70

Service Code	HCPCS C1725
Hospital Charge Code	41569140
Hospital Revenue Code	278
Min. Negotiated Rate	$275.35
Max. Negotiated Rate	$275.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$275.35
Rate for Payer: Hamaspik Choice Inc Medicare	$275.35

ZZ BALLOON/BLUEMAX/10-4-75CM

Facility OP

$550.70

Service Code	HCPCS C1725
Hospital Charge Code	41569140
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$578.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$302.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.85
Rate for Payer: Aetna Government	$44.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$275.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$316.65
Rate for Payer: Fidelis Medicare Advantage	$578.24
Rate for Payer: Group Health Inc Commercial	$275.35
Rate for Payer: Group Health Inc Medicare	$192.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$275.35
Rate for Payer: Hamaspik Choice Inc Medicare	$275.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$357.96

ZZ BALLOON/BLUEMAX/12-4-100CM

Facility OP

$582.59

Service Code	HCPCS C1725
Hospital Charge Code	41569139
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$611.72
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$320.42
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.85
Rate for Payer: Aetna Government	$44.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$291.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$334.99
Rate for Payer: Fidelis Medicare Advantage	$611.72
Rate for Payer: Group Health Inc Commercial	$291.30
Rate for Payer: Group Health Inc Medicare	$203.91
Rate for Payer: Hamaspik Choice Inc Medicaid	$291.30
Rate for Payer: Hamaspik Choice Inc Medicare	$291.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$378.68

ZZ BALLOON/BLUEMAX/12-4-100CM

Facility IP

$582.59

Service Code	HCPCS C1725
Hospital Charge Code	41569139
Hospital Revenue Code	278
Min. Negotiated Rate	$291.30
Max. Negotiated Rate	$291.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$291.30
Rate for Payer: Hamaspik Choice Inc Medicare	$291.30

ZZ BALLOON/BLUEMAX/8-3-40CM

Facility OP

$550.70

Service Code	HCPCS C1725
Hospital Charge Code	41569141
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$578.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$302.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.85
Rate for Payer: Aetna Government	$44.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$275.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$316.65
Rate for Payer: Fidelis Medicare Advantage	$578.24
Rate for Payer: Group Health Inc Commercial	$275.35
Rate for Payer: Group Health Inc Medicare	$192.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$275.35
Rate for Payer: Hamaspik Choice Inc Medicare	$275.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$357.96

ZZ BALLOON/BLUEMAX/8-3-40CM

Facility IP

$550.70

Service Code	HCPCS C1725
Hospital Charge Code	41569141
Hospital Revenue Code	278
Min. Negotiated Rate	$275.35
Max. Negotiated Rate	$275.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$275.35
Rate for Payer: Hamaspik Choice Inc Medicare	$275.35

ZZ BALLOON/BLUEMAX/9-4-75CM

Facility OP

$550.70

Service Code	HCPCS C1725
Hospital Charge Code	41569142
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$578.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$302.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.85
Rate for Payer: Aetna Government	$44.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$275.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$316.65
Rate for Payer: Fidelis Medicare Advantage	$578.24
Rate for Payer: Group Health Inc Commercial	$275.35
Rate for Payer: Group Health Inc Medicare	$192.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$275.35
Rate for Payer: Hamaspik Choice Inc Medicare	$275.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$357.96

ZZ BALLOON/BLUEMAX/9-4-75CM

Facility IP

$550.70

Service Code	HCPCS C1725
Hospital Charge Code	41569142
Hospital Revenue Code	278
Min. Negotiated Rate	$275.35
Max. Negotiated Rate	$275.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$275.35
Rate for Payer: Hamaspik Choice Inc Medicare	$275.35

ZZ BALLOON MARSHAL 10-4 5.8T 90

Facility OP

$542.20

Service Code	HCPCS C1725
Hospital Charge Code	41569023
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$569.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$298.21
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.85
Rate for Payer: Aetna Government	$44.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$271.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$311.76
Rate for Payer: Fidelis Medicare Advantage	$569.31
Rate for Payer: Group Health Inc Commercial	$271.10
Rate for Payer: Group Health Inc Medicare	$189.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$271.10
Rate for Payer: Hamaspik Choice Inc Medicare	$271.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$352.43

ZZ BALLOON MARSHAL 10-4 5.8T 90

Facility IP

$542.20

Service Code	HCPCS C1725
Hospital Charge Code	41569023
Hospital Revenue Code	278
Min. Negotiated Rate	$271.10
Max. Negotiated Rate	$271.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$271.10
Rate for Payer: Hamaspik Choice Inc Medicare	$271.10

ZZ BALLOON MARSHAL 5-2 5.2T

Facility OP

$542.20

Hospital Charge Code	41569017
Hospital Revenue Code	270
Min. Negotiated Rate	$189.77
Max. Negotiated Rate	$433.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$298.21
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$271.10
Rate for Payer: Aetna Government	$271.10
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$433.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$368.70
Rate for Payer: Group Health Inc Commercial	$271.10
Rate for Payer: Group Health Inc Medicare	$189.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$271.10
Rate for Payer: Hamaspik Choice Inc Medicare	$271.10

ZZ BALLOON MARSHAL 6-2 5.2T 90

Facility OP

$542.20

Service Code	HCPCS C1725
Hospital Charge Code	41569018
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$569.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$298.21
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.85
Rate for Payer: Aetna Government	$44.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$271.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$311.76
Rate for Payer: Fidelis Medicare Advantage	$569.31
Rate for Payer: Group Health Inc Commercial	$271.10
Rate for Payer: Group Health Inc Medicare	$189.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$271.10
Rate for Payer: Hamaspik Choice Inc Medicare	$271.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$352.43

ZZ BALLOON MARSHAL 6-2 5.2T 90

Facility IP

$542.20

Service Code	HCPCS C1725
Hospital Charge Code	41569018
Hospital Revenue Code	278
Min. Negotiated Rate	$271.10
Max. Negotiated Rate	$271.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$271.10
Rate for Payer: Hamaspik Choice Inc Medicare	$271.10

ZZ BALLOON MARSHAL 6-4 5.2T 90

Facility OP

$542.20

Service Code	HCPCS C1725
Hospital Charge Code	41569019
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$569.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$298.21
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.85
Rate for Payer: Aetna Government	$44.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$271.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$311.76
Rate for Payer: Fidelis Medicare Advantage	$569.31
Rate for Payer: Group Health Inc Commercial	$271.10
Rate for Payer: Group Health Inc Medicare	$189.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$271.10
Rate for Payer: Hamaspik Choice Inc Medicare	$271.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$352.43

ZZ BALLOON MARSHAL 6-4 5.2T 90

Facility IP

$542.20

Service Code	HCPCS C1725
Hospital Charge Code	41569019
Hospital Revenue Code	278
Min. Negotiated Rate	$271.10
Max. Negotiated Rate	$271.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$271.10
Rate for Payer: Hamaspik Choice Inc Medicare	$271.10

ZZ BALLOON MARSHAL 7-4 5.8T 90

Facility IP

$542.20

Service Code	HCPCS C1725
Hospital Charge Code	41569020
Hospital Revenue Code	278
Min. Negotiated Rate	$271.10
Max. Negotiated Rate	$271.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$271.10
Rate for Payer: Hamaspik Choice Inc Medicare	$271.10

ZZ BALLOON MARSHAL 7-4 5.8T 90

Facility OP

$542.20

Service Code	HCPCS C1725
Hospital Charge Code	41569020
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$569.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$298.21
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.85
Rate for Payer: Aetna Government	$44.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$271.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$311.76
Rate for Payer: Fidelis Medicare Advantage	$569.31
Rate for Payer: Group Health Inc Commercial	$271.10
Rate for Payer: Group Health Inc Medicare	$189.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$271.10
Rate for Payer: Hamaspik Choice Inc Medicare	$271.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$352.43

ZZ BALLOON MARSHAL 8-2 5.8T 90

Facility OP

$542.20

Hospital Charge Code	41569021
Hospital Revenue Code	270
Min. Negotiated Rate	$189.77
Max. Negotiated Rate	$433.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$298.21
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$271.10
Rate for Payer: Aetna Government	$271.10
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$433.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$368.70
Rate for Payer: Group Health Inc Commercial	$271.10
Rate for Payer: Group Health Inc Medicare	$189.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$271.10
Rate for Payer: Hamaspik Choice Inc Medicare	$271.10

ZZ BALLOON MARSHAL 9-4 5.8T 90

Facility OP

$542.20

Service Code	HCPCS C1725
Hospital Charge Code	41569022
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$569.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$298.21
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.85
Rate for Payer: Aetna Government	$44.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$271.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$311.76
Rate for Payer: Fidelis Medicare Advantage	$569.31
Rate for Payer: Group Health Inc Commercial	$271.10
Rate for Payer: Group Health Inc Medicare	$189.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$271.10
Rate for Payer: Hamaspik Choice Inc Medicare	$271.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$352.43

ZZ BALLOON MARSHAL 9-4 5.8T 90

Facility IP

$542.20

Service Code	HCPCS C1725
Hospital Charge Code	41569022
Hospital Revenue Code	278
Min. Negotiated Rate	$271.10
Max. Negotiated Rate	$271.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$271.10
Rate for Payer: Hamaspik Choice Inc Medicare	$271.10

ZZ BALLOON MARSHALL 7X6

Facility IP

$578.34

Service Code	HCPCS C1725
Hospital Charge Code	41569626
Hospital Revenue Code	278
Min. Negotiated Rate	$289.17
Max. Negotiated Rate	$289.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$289.17
Rate for Payer: Hamaspik Choice Inc Medicare	$289.17

ZZ BALLOON MARSHALL 7X6

Facility OP

$578.34

Service Code	HCPCS C1725
Hospital Charge Code	41569626
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$607.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$318.09
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.85
Rate for Payer: Aetna Government	$44.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$289.17
Rate for Payer: Cigna LocalPlus Benefit Plan	$332.55
Rate for Payer: Fidelis Medicare Advantage	$607.26
Rate for Payer: Group Health Inc Commercial	$289.17
Rate for Payer: Group Health Inc Medicare	$202.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$289.17
Rate for Payer: Hamaspik Choice Inc Medicare	$289.17
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$375.92

ZZ BALLOON/OCCLUSION/LARGE 20MM

Facility OP

$361.46

Service Code	HCPCS C1725
Hospital Charge Code	41569143
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$379.53
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$198.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.85
Rate for Payer: Aetna Government	$44.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$180.73
Rate for Payer: Cigna LocalPlus Benefit Plan	$207.84
Rate for Payer: Fidelis Medicare Advantage	$379.53
Rate for Payer: Group Health Inc Commercial	$180.73
Rate for Payer: Group Health Inc Medicare	$126.51
Rate for Payer: Hamaspik Choice Inc Medicaid	$180.73
Rate for Payer: Hamaspik Choice Inc Medicare	$180.73
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$234.95

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