St. Barnabas Hospital

All Charges

Charge

Type

Price

ZZ BALLOON SYMMETRY 4.5X2X135

Facility OP

$965.32

Hospital Charge Code	41569683
Hospital Revenue Code	270
Min. Negotiated Rate	$337.86
Max. Negotiated Rate	$772.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$530.93
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$482.66
Rate for Payer: Aetna Government	$482.66
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$772.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$656.42
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

ZZ BALLOON/SYMMETRY/6-2-90

Facility IP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569087
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/6-2-90

Facility OP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569087
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/6-4-90

Facility IP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569088
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/6-4-90

Facility OP

$784.59

Service Code	HCPCS C1725
Hospital Charge Code	41569088
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/SS/2.5-2-135

Facility OP

$827.12

Service Code	HCPCS C1725
Hospital Charge Code	41569098
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/SS/2.5-2-135

Facility IP

$827.12

Service Code	HCPCS C1725
Hospital Charge Code	41569098
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

ZZ BALLOON/SYMMETRY/SS/3-2-135

Facility OP

$827.12

Service Code	HCPCS C1725
Hospital Charge Code	41569099
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/SS/3-2-135

Facility IP

$827.12

Service Code	HCPCS C1725
Hospital Charge Code	41569099
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

ZZ BALLOON/SYMMETRY/SS/3.5-2-135

Facility OP

$827.12

Service Code	HCPCS C1725
Hospital Charge Code	41569100
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/SS/3.5-2-135

Facility IP

$827.12

Service Code	HCPCS C1725
Hospital Charge Code	41569100
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

ZZ BALLOON/SYMMETRY/SS/5-2-135

Facility OP

$827.12

Service Code	HCPCS C1725
Hospital Charge Code	41569103
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/SS/5-2-135

Facility IP

$827.12

Service Code	HCPCS C1725
Hospital Charge Code	41569103
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

ZZ BALLOON/SYMMETRY/SS/5-4-135

Facility IP

$827.12

Service Code	HCPCS C1725
Hospital Charge Code	41569104
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

ZZ BALLOON/SYMMETRY/SS/5-4-135

Facility OP

$827.12

Service Code	HCPCS C1725
Hospital Charge Code	41569104
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/S-S/6-4-135

Facility IP

$827.12

Service Code	HCPCS C1725
Hospital Charge Code	41569089
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

ZZ BALLOON/SYMMETRY/S-S/6-4-135

Facility OP

$827.12

Service Code	HCPCS C1725
Hospital Charge Code	41569089
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/ULTRATHIN DIAM/6-2

Facility OP

$542.20

Service Code	HCPCS C1725
Hospital Charge Code	41569105
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/ULTRATHIN DIAM/6-2

Facility IP

$542.20

Service Code	HCPCS C1725
Hospital Charge Code	41569105
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/UT/DIAMOND/10-2-75

Facility IP

$574.09

Service Code	HCPCS C1725
Hospital Charge Code	41569106
Hospital Revenue Code	278
Min. Negotiated Rate	$287.04
Max. Negotiated Rate	$287.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$287.04
Rate for Payer: Hamaspik Choice Inc Medicare	$287.04

ZZ BALLOON/UT/DIAMOND/10-2-75

Facility OP

$574.09

Service Code	HCPCS C1725
Hospital Charge Code	41569106
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$602.79
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$315.75
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	$287.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$330.10
Rate for Payer: Fidelis Medicare Advantage	$602.79
Rate for Payer: Group Health Inc Commercial	$287.04
Rate for Payer: Group Health Inc Medicare	$200.93
Rate for Payer: Hamaspik Choice Inc Medicaid	$287.04
Rate for Payer: Hamaspik Choice Inc Medicare	$287.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$373.16

ZZ BALLOON/UT/DIAMOND/10-4-120

Facility IP

$574.09

Service Code	HCPCS C1725
Hospital Charge Code	41569108
Hospital Revenue Code	278
Min. Negotiated Rate	$287.04
Max. Negotiated Rate	$287.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$287.04
Rate for Payer: Hamaspik Choice Inc Medicare	$287.04

ZZ BALLOON/UT/DIAMOND/10-4-120

Facility OP

$574.09

Service Code	HCPCS C1725
Hospital Charge Code	41569108
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$602.79
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$315.75
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	$287.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$330.10
Rate for Payer: Fidelis Medicare Advantage	$602.79
Rate for Payer: Group Health Inc Commercial	$287.04
Rate for Payer: Group Health Inc Medicare	$200.93
Rate for Payer: Hamaspik Choice Inc Medicaid	$287.04
Rate for Payer: Hamaspik Choice Inc Medicare	$287.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$373.16

ZZ BALLOON/UT/DIAMOND/10-4-75

Facility OP

$574.09

Service Code	HCPCS C1725
Hospital Charge Code	41569109
Hospital Revenue Code	278
Min. Negotiated Rate	$44.85
Max. Negotiated Rate	$602.79
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$315.75
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	$287.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$330.10
Rate for Payer: Fidelis Medicare Advantage	$602.79
Rate for Payer: Group Health Inc Commercial	$287.04
Rate for Payer: Group Health Inc Medicare	$200.93
Rate for Payer: Hamaspik Choice Inc Medicaid	$287.04
Rate for Payer: Hamaspik Choice Inc Medicare	$287.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$373.16

ZZ BALLOON/UT/DIAMOND/10-4-75

Facility IP

$574.09

Service Code	HCPCS C1725
Hospital Charge Code	41569109
Hospital Revenue Code	278
Min. Negotiated Rate	$287.04
Max. Negotiated Rate	$287.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$287.04
Rate for Payer: Hamaspik Choice Inc Medicare	$287.04

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