St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

CHG CT LOWER EXTREMITY W/O CONTRAST MATERIAL

Professional

Both

$376.50

Service Code	HCPCS 73700 TC
Min. Negotiated Rate	$282.38
Max. Negotiated Rate	$282.38
Rate for Payer: Cash Price	$101.61
Rate for Payer: SOMOS CHP/HARP/Medicaid	$282.38
Rate for Payer: SOMOS Essential	$282.38

CHG CT LOWER EXTREMITY W/O CONTRAST MATERIAL

Professional

Both

$187.95

Service Code	HCPCS 73700 26
Min. Negotiated Rate	$140.96
Max. Negotiated Rate	$140.96
Rate for Payer: Cash Price	$51.75
Rate for Payer: SOMOS CHP/HARP/Medicaid	$140.96
Rate for Payer: SOMOS Essential	$140.96

CHG CT LOWER EXTREMITY W/O CONTRAST MATERIAL

Professional

Both

$564.41

Service Code	HCPCS 73700
Min. Negotiated Rate	$423.31
Max. Negotiated Rate	$423.31
Rate for Payer: Cash Price	$153.36
Rate for Payer: SOMOS CHP/HARP/Medicaid	$423.31
Rate for Payer: SOMOS Essential	$423.31

CHG CT LOWER EXTREMITY W/O & W/CONTRAST MATRL

Professional

Both

$231.04

Service Code	HCPCS 73702 26
Min. Negotiated Rate	$173.28
Max. Negotiated Rate	$173.28
Rate for Payer: Cash Price	$62.80
Rate for Payer: SOMOS CHP/HARP/Medicaid	$173.28
Rate for Payer: SOMOS Essential	$173.28

CHG CT LOWER EXTREMITY W/O & W/CONTRAST MATRL

Professional

Both

$629.34

Service Code	HCPCS 73702 TC
Min. Negotiated Rate	$472.00
Max. Negotiated Rate	$472.00
Rate for Payer: Cash Price	$169.82
Rate for Payer: SOMOS CHP/HARP/Medicaid	$472.00
Rate for Payer: SOMOS Essential	$472.00

CHG CT LOWER EXTREMITY W/O & W/CONTRAST MATRL

Professional

Both

$860.37

Service Code	HCPCS 73702
Min. Negotiated Rate	$645.28
Max. Negotiated Rate	$645.28
Rate for Payer: Cash Price	$232.62
Rate for Payer: SOMOS CHP/HARP/Medicaid	$645.28
Rate for Payer: SOMOS Essential	$645.28

CHG CT LUMBAR SPINE W/CONTRAST MATERIAL

Professional

Both

$232.47

Service Code	HCPCS 72132 26
Min. Negotiated Rate	$174.35
Max. Negotiated Rate	$174.35
Rate for Payer: Cash Price	$63.19
Rate for Payer: SOMOS CHP/HARP/Medicaid	$174.35
Rate for Payer: SOMOS Essential	$174.35

CHG CT LUMBAR SPINE W/CONTRAST MATERIAL

Professional

Both

$742.49

Service Code	HCPCS 72132
Min. Negotiated Rate	$556.87
Max. Negotiated Rate	$556.87
Rate for Payer: Cash Price	$200.79
Rate for Payer: SOMOS CHP/HARP/Medicaid	$556.87
Rate for Payer: SOMOS Essential	$556.87

CHG CT LUMBAR SPINE W/CONTRAST MATERIAL

Professional

Both

$510.02

Service Code	HCPCS 72132 TC
Min. Negotiated Rate	$382.52
Max. Negotiated Rate	$382.52
Rate for Payer: Cash Price	$137.60
Rate for Payer: SOMOS CHP/HARP/Medicaid	$382.52
Rate for Payer: SOMOS Essential	$382.52

CHG CT LUMBAR SPINE W/O CONTRAST MATERIAL

Professional

Both

$562.98

Service Code	HCPCS 72131
Min. Negotiated Rate	$422.24
Max. Negotiated Rate	$422.24
Rate for Payer: Cash Price	$152.97
Rate for Payer: SOMOS CHP/HARP/Medicaid	$422.24
Rate for Payer: SOMOS Essential	$422.24

CHG CT LUMBAR SPINE W/O CONTRAST MATERIAL

Professional

Both

$375.06

Service Code	HCPCS 72131 TC
Min. Negotiated Rate	$281.30
Max. Negotiated Rate	$281.30
Rate for Payer: Cash Price	$101.22
Rate for Payer: SOMOS CHP/HARP/Medicaid	$281.30
Rate for Payer: SOMOS Essential	$281.30

CHG CT LUMBAR SPINE W/O CONTRAST MATERIAL

Professional

Both

$187.95

Service Code	HCPCS 72131 26
Min. Negotiated Rate	$140.96
Max. Negotiated Rate	$140.96
Rate for Payer: Cash Price	$51.75
Rate for Payer: SOMOS CHP/HARP/Medicaid	$140.96
Rate for Payer: SOMOS Essential	$140.96

CHG CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL

Professional

Both

$244.34

Service Code	HCPCS 72133 26
Min. Negotiated Rate	$183.26
Max. Negotiated Rate	$183.26
Rate for Payer: Cash Price	$65.96
Rate for Payer: SOMOS CHP/HARP/Medicaid	$183.26
Rate for Payer: SOMOS Essential	$183.26

CHG CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL

Professional

Both

$629.34

Service Code	HCPCS 72133 TC
Min. Negotiated Rate	$472.00
Max. Negotiated Rate	$472.00
Rate for Payer: Cash Price	$169.82
Rate for Payer: SOMOS CHP/HARP/Medicaid	$472.00
Rate for Payer: SOMOS Essential	$472.00

CHG CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL

Professional

Both

$873.67

Service Code	HCPCS 72133
Min. Negotiated Rate	$655.25
Max. Negotiated Rate	$655.25
Rate for Payer: Cash Price	$235.78
Rate for Payer: SOMOS CHP/HARP/Medicaid	$655.25
Rate for Payer: SOMOS Essential	$655.25

CHG CT MAXILLOFACIAL W/CONTRAST MATERIAL

Professional

Both

$449.79

Service Code	HCPCS 70487 TC
Min. Negotiated Rate	$337.34
Max. Negotiated Rate	$337.34
Rate for Payer: Cash Price	$122.27
Rate for Payer: SOMOS CHP/HARP/Medicaid	$337.34
Rate for Payer: SOMOS Essential	$337.34

CHG CT MAXILLOFACIAL W/CONTRAST MATERIAL

Professional

Both

$666.68

Service Code	HCPCS 70487
Min. Negotiated Rate	$500.01
Max. Negotiated Rate	$500.01
Rate for Payer: Cash Price	$180.76
Rate for Payer: SOMOS CHP/HARP/Medicaid	$500.01
Rate for Payer: SOMOS Essential	$500.01

CHG CT MAXILLOFACIAL W/CONTRAST MATERIAL

Professional

Both

$216.90

Service Code	HCPCS 70487 26
Min. Negotiated Rate	$162.68
Max. Negotiated Rate	$162.68
Rate for Payer: Cash Price	$58.48
Rate for Payer: SOMOS CHP/HARP/Medicaid	$162.68
Rate for Payer: SOMOS Essential	$162.68

CHG CT MAXILLOFACIAL W/O CONTRAST MATERIAL

Professional

Both

$562.91

Service Code	HCPCS 70486
Min. Negotiated Rate	$422.18
Max. Negotiated Rate	$422.18
Rate for Payer: Cash Price	$152.22
Rate for Payer: SOMOS CHP/HARP/Medicaid	$422.18
Rate for Payer: SOMOS Essential	$422.18

CHG CT MAXILLOFACIAL W/O CONTRAST MATERIAL

Professional

Both

$399.49

Service Code	HCPCS 70486 TC
Min. Negotiated Rate	$299.62
Max. Negotiated Rate	$299.62
Rate for Payer: Cash Price	$107.90
Rate for Payer: SOMOS CHP/HARP/Medicaid	$299.62
Rate for Payer: SOMOS Essential	$299.62

CHG CT MAXILLOFACIAL W/O CONTRAST MATERIAL

Professional

Both

$163.42

Service Code	HCPCS 70486 26
Min. Negotiated Rate	$122.56
Max. Negotiated Rate	$122.56
Rate for Payer: Cash Price	$44.33
Rate for Payer: SOMOS CHP/HARP/Medicaid	$122.56
Rate for Payer: SOMOS Essential	$122.56

CHG CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL

Professional

Both

$814.77

Service Code	HCPCS 70488
Min. Negotiated Rate	$611.08
Max. Negotiated Rate	$611.08
Rate for Payer: Cash Price	$219.27
Rate for Payer: SOMOS CHP/HARP/Medicaid	$611.08
Rate for Payer: SOMOS Essential	$611.08

CHG CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL

Professional

Both

$570.40

Service Code	HCPCS 70488 TC
Min. Negotiated Rate	$427.80
Max. Negotiated Rate	$427.80
Rate for Payer: Cash Price	$153.32
Rate for Payer: SOMOS CHP/HARP/Medicaid	$427.80
Rate for Payer: SOMOS Essential	$427.80

CHG CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL

Professional

Both

$244.34

Service Code	HCPCS 70488 26
Min. Negotiated Rate	$183.26
Max. Negotiated Rate	$183.26
Rate for Payer: Cash Price	$65.96
Rate for Payer: SOMOS CHP/HARP/Medicaid	$183.26
Rate for Payer: SOMOS Essential	$183.26

CHG CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL

Professional

Both

$580.48

Service Code	HCPCS 70481 TC
Min. Negotiated Rate	$435.36
Max. Negotiated Rate	$435.36
Rate for Payer: Cash Price	$156.46
Rate for Payer: SOMOS CHP/HARP/Medicaid	$435.36
Rate for Payer: SOMOS Essential	$435.36

Know your out-of-pocket cost for care.

All Charges