St. Barnabas Hospital

All Charges

Charge

Type

Price

ZZ BALLOON/OCCLUSION/LARGE 20MM

Facility IP

$361.46

Service Code	HCPCS C1725
Hospital Charge Code	41569143
Hospital Revenue Code	278
Min. Negotiated Rate	$180.73
Max. Negotiated Rate	$180.73
Rate for Payer: Hamaspik Choice Inc Medicaid	$180.73
Rate for Payer: Hamaspik Choice Inc Medicare	$180.73

ZZ BALLOON/OCCLUSION/MEDIUM 13MM

Facility IP

$382.73

Service Code	HCPCS C1725
Hospital Charge Code	41569144
Hospital Revenue Code	278
Min. Negotiated Rate	$191.36
Max. Negotiated Rate	$191.36
Rate for Payer: Hamaspik Choice Inc Medicaid	$191.36
Rate for Payer: Hamaspik Choice Inc Medicare	$191.36

ZZ BALLOON/OCCLUSION/MEDIUM 13MM

Facility OP

$382.73

Service Code	HCPCS C1725
Hospital Charge Code	41569144
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$401.87
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$210.50
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	$191.36
Rate for Payer: Cigna LocalPlus Benefit Plan	$220.07
Rate for Payer: Fidelis Medicare Advantage	$401.87
Rate for Payer: Group Health Inc Commercial	$191.36
Rate for Payer: Group Health Inc Medicare	$133.96
Rate for Payer: Hamaspik Choice Inc Medicaid	$191.36
Rate for Payer: Hamaspik Choice Inc Medicare	$191.36
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$248.77

ZZ BALLOON/OCCLUSION/SMALL 8.5MM

Facility OP

$372.10

Service Code	HCPCS C1725
Hospital Charge Code	41569086
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$390.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$204.66
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	$186.05
Rate for Payer: Cigna LocalPlus Benefit Plan	$213.96
Rate for Payer: Fidelis Medicare Advantage	$390.70
Rate for Payer: Group Health Inc Commercial	$186.05
Rate for Payer: Group Health Inc Medicare	$130.24
Rate for Payer: Hamaspik Choice Inc Medicaid	$186.05
Rate for Payer: Hamaspik Choice Inc Medicare	$186.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$241.86

ZZ BALLOON/OCCLUSION/SMALL 8.5MM

Facility IP

$372.10

Service Code	HCPCS C1725
Hospital Charge Code	41569086
Hospital Revenue Code	278
Min. Negotiated Rate	$186.05
Max. Negotiated Rate	$186.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$186.05
Rate for Payer: Hamaspik Choice Inc Medicare	$186.05

ZZ BALLOON/SYMMETRY/14-2-90

Facility OP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569094
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$823.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$431.52
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	$392.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$451.14
Rate for Payer: Fidelis Medicare Advantage	$823.82
Rate for Payer: Group Health Inc Commercial	$392.30
Rate for Payer: Group Health Inc Medicare	$274.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$392.30
Rate for Payer: Hamaspik Choice Inc Medicare	$392.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$509.98

ZZ BALLOON/SYMMETRY/14-2-90

Facility IP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569094
Hospital Revenue Code	278
Min. Negotiated Rate	$392.30
Max. Negotiated Rate	$392.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$392.30
Rate for Payer: Hamaspik Choice Inc Medicare	$392.30

ZZ BALLOON/SYMMETRY/15-2-90

Facility IP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569095
Hospital Revenue Code	278
Min. Negotiated Rate	$392.30
Max. Negotiated Rate	$392.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$392.30
Rate for Payer: Hamaspik Choice Inc Medicare	$392.30

ZZ BALLOON/SYMMETRY/15-2-90

Facility OP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569095
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$823.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$431.52
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	$392.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$451.14
Rate for Payer: Fidelis Medicare Advantage	$823.82
Rate for Payer: Group Health Inc Commercial	$392.30
Rate for Payer: Group Health Inc Medicare	$274.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$392.30
Rate for Payer: Hamaspik Choice Inc Medicare	$392.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$509.98

ZZ BALLOON/SYMMETRY/15-4-90

Facility OP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569096
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$823.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$431.52
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	$392.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$451.14
Rate for Payer: Fidelis Medicare Advantage	$823.82
Rate for Payer: Group Health Inc Commercial	$392.30
Rate for Payer: Group Health Inc Medicare	$274.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$392.30
Rate for Payer: Hamaspik Choice Inc Medicare	$392.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$509.98

ZZ BALLOON/SYMMETRY/15-4-90

Facility IP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569096
Hospital Revenue Code	278
Min. Negotiated Rate	$392.30
Max. Negotiated Rate	$392.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$392.30
Rate for Payer: Hamaspik Choice Inc Medicare	$392.30

ZZ BALLOON/SYMMETRY/2-2-90

Facility IP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569090
Hospital Revenue Code	278
Min. Negotiated Rate	$392.30
Max. Negotiated Rate	$392.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$392.30
Rate for Payer: Hamaspik Choice Inc Medicare	$392.30

ZZ BALLOON/SYMMETRY/2-2-90

Facility OP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569090
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$823.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$431.52
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	$392.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$451.14
Rate for Payer: Fidelis Medicare Advantage	$823.82
Rate for Payer: Group Health Inc Commercial	$392.30
Rate for Payer: Group Health Inc Medicare	$274.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$392.30
Rate for Payer: Hamaspik Choice Inc Medicare	$392.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$509.98

ZZ BALLOON/SYMMETRY/2.5-2-90

Facility IP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569091
Hospital Revenue Code	278
Min. Negotiated Rate	$392.30
Max. Negotiated Rate	$392.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$392.30
Rate for Payer: Hamaspik Choice Inc Medicare	$392.30

ZZ BALLOON/SYMMETRY/2.5-2-90

Facility OP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569091
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$823.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$431.52
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	$392.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$451.14
Rate for Payer: Fidelis Medicare Advantage	$823.82
Rate for Payer: Group Health Inc Commercial	$392.30
Rate for Payer: Group Health Inc Medicare	$274.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$392.30
Rate for Payer: Hamaspik Choice Inc Medicare	$392.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$509.98

ZZ BALLOON SYMMETRY 2X2.5X135

Facility IP

$965.32

Service Code	HCPCS C1725
Hospital Charge Code	41569682
Hospital Revenue Code	278
Min. Negotiated Rate	$482.66
Max. Negotiated Rate	$482.66
Rate for Payer: Hamaspik Choice Inc Medicaid	$482.66
Rate for Payer: Hamaspik Choice Inc Medicare	$482.66

ZZ BALLOON SYMMETRY 2X2.5X135

Facility OP

$965.32

Service Code	HCPCS C1725
Hospital Charge Code	41569682
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$1,013.59
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$530.93
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	$482.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$555.06
Rate for Payer: Fidelis Medicare Advantage	$1,013.59
Rate for Payer: Group Health Inc Commercial	$482.66
Rate for Payer: Group Health Inc Medicare	$337.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$482.66
Rate for Payer: Hamaspik Choice Inc Medicare	$482.66
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$627.46

ZZ BALLOON SYMMETRY 2X2X135

Facility OP

$965.32

Service Code	HCPCS C1725
Hospital Charge Code	41569681
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$1,013.59
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$530.93
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	$482.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$555.06
Rate for Payer: Fidelis Medicare Advantage	$1,013.59
Rate for Payer: Group Health Inc Commercial	$482.66
Rate for Payer: Group Health Inc Medicare	$337.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$482.66
Rate for Payer: Hamaspik Choice Inc Medicare	$482.66
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$627.46

ZZ BALLOON SYMMETRY 2X2X135

Facility IP

$965.32

Service Code	HCPCS C1725
Hospital Charge Code	41569681
Hospital Revenue Code	278
Min. Negotiated Rate	$482.66
Max. Negotiated Rate	$482.66
Rate for Payer: Hamaspik Choice Inc Medicaid	$482.66
Rate for Payer: Hamaspik Choice Inc Medicare	$482.66

ZZ BALLOON/SYMMETRY/3-2-90

Facility IP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569092
Hospital Revenue Code	278
Min. Negotiated Rate	$392.30
Max. Negotiated Rate	$392.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$392.30
Rate for Payer: Hamaspik Choice Inc Medicare	$392.30

ZZ BALLOON/SYMMETRY/3-2-90

Facility OP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569092
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$823.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$431.52
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	$392.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$451.14
Rate for Payer: Fidelis Medicare Advantage	$823.82
Rate for Payer: Group Health Inc Commercial	$392.30
Rate for Payer: Group Health Inc Medicare	$274.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$392.30
Rate for Payer: Hamaspik Choice Inc Medicare	$392.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$509.98

ZZ BALLOON/SYMMETRY/35-2-90

Facility IP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569093
Hospital Revenue Code	278
Min. Negotiated Rate	$392.30
Max. Negotiated Rate	$392.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$392.30
Rate for Payer: Hamaspik Choice Inc Medicare	$392.30

ZZ BALLOON/SYMMETRY/35-2-90

Facility OP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569093
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$823.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$431.52
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	$392.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$451.14
Rate for Payer: Fidelis Medicare Advantage	$823.82
Rate for Payer: Group Health Inc Commercial	$392.30
Rate for Payer: Group Health Inc Medicare	$274.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$392.30
Rate for Payer: Hamaspik Choice Inc Medicare	$392.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$509.98

ZZ BALLOON/SYMMETRY/4-2-135

Facility OP

$827.12

Service Code	HCPCS C1725
Hospital Charge Code	41569102
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$868.48
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$454.92
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	$413.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$475.59
Rate for Payer: Fidelis Medicare Advantage	$868.48
Rate for Payer: Group Health Inc Commercial	$413.56
Rate for Payer: Group Health Inc Medicare	$289.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$413.56
Rate for Payer: Hamaspik Choice Inc Medicare	$413.56
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$537.63

ZZ BALLOON/SYMMETRY/4-2-135

Facility IP

$827.12

Service Code	HCPCS C1725
Hospital Charge Code	41569102
Hospital Revenue Code	278
Min. Negotiated Rate	$413.56
Max. Negotiated Rate	$413.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$413.56
Rate for Payer: Hamaspik Choice Inc Medicare	$413.56

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