St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

CHG PERINEOGRAM

Professional

Both

$295.12

Service Code	HCPCS 74775 TC
Min. Negotiated Rate	$221.34
Max. Negotiated Rate	$221.34
Rate for Payer: SOMOS CHP/HARP/Medicaid	$221.34
Rate for Payer: SOMOS Essential	$221.34

CHG PERINEOGRAM

Professional

Both

$416.78

Service Code	HCPCS 74775
Min. Negotiated Rate	$312.58
Max. Negotiated Rate	$312.58
Rate for Payer: SOMOS CHP/HARP/Medicaid	$312.58
Rate for Payer: SOMOS Essential	$312.58

CHG PERITONEAL-VENOUS SHUNT PATENCY TEST

Professional

Both

$884.94

Service Code	HCPCS 78291 TC
Min. Negotiated Rate	$663.70
Max. Negotiated Rate	$663.70
Rate for Payer: Cash Price	$238.10
Rate for Payer: SOMOS CHP/HARP/Medicaid	$663.70
Rate for Payer: SOMOS Essential	$663.70

CHG PERITONEAL-VENOUS SHUNT PATENCY TEST

Professional

Both

$167.16

Service Code	HCPCS 78291 26
Min. Negotiated Rate	$125.37
Max. Negotiated Rate	$125.37
Rate for Payer: Cash Price	$46.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$125.37
Rate for Payer: SOMOS Essential	$125.37

CHG PERITONEAL-VENOUS SHUNT PATENCY TEST

Professional

Both

$1,052.10

Service Code	HCPCS 78291
Min. Negotiated Rate	$789.08
Max. Negotiated Rate	$789.08
Rate for Payer: Cash Price	$284.10
Rate for Payer: SOMOS CHP/HARP/Medicaid	$789.08
Rate for Payer: SOMOS Essential	$789.08

CHG PERITONEOGRAM RS&I

Professional

Both

$264.32

Service Code	HCPCS 74190 TC
Min. Negotiated Rate	$198.24
Max. Negotiated Rate	$198.24
Rate for Payer: SOMOS CHP/HARP/Medicaid	$198.24
Rate for Payer: SOMOS Essential	$198.24

CHG PERITONEOGRAM RS&I

Professional

Both

$91.18

Service Code	HCPCS 74190 26
Min. Negotiated Rate	$68.38
Max. Negotiated Rate	$68.38
Rate for Payer: Cash Price	$24.12
Rate for Payer: SOMOS CHP/HARP/Medicaid	$68.38
Rate for Payer: SOMOS Essential	$68.38

CHG PERITONEOGRAM RS&I

Professional

Both

$355.50

Service Code	HCPCS 74190
Min. Negotiated Rate	$266.62
Max. Negotiated Rate	$266.62
Rate for Payer: SOMOS CHP/HARP/Medicaid	$266.62
Rate for Payer: SOMOS Essential	$266.62

CHG PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH

Professional

Both

$6,771.24

Service Code	HCPCS 78815
Min. Negotiated Rate	$5,078.43
Max. Negotiated Rate	$5,078.43
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5,078.43
Rate for Payer: SOMOS Essential	$5,078.43

CHG PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH

Professional

Both

$6,319.08

Service Code	HCPCS 78815 TC
Min. Negotiated Rate	$4,739.31
Max. Negotiated Rate	$4,739.31
Rate for Payer: SOMOS CHP/HARP/Medicaid	$4,739.31
Rate for Payer: SOMOS Essential	$4,739.31

CHG PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH

Professional

Both

$452.13

Service Code	HCPCS 78815 26
Min. Negotiated Rate	$339.10
Max. Negotiated Rate	$339.10
Rate for Payer: Cash Price	$122.62
Rate for Payer: SOMOS CHP/HARP/Medicaid	$339.10
Rate for Payer: SOMOS Essential	$339.10

CHG PET IMAGING CT FOR ATTENUATION LIMITED AREA

Professional

Both

$6,726.93

Service Code	HCPCS 78814
Min. Negotiated Rate	$5,045.20
Max. Negotiated Rate	$5,045.20
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5,045.20
Rate for Payer: SOMOS Essential	$5,045.20

CHG PET IMAGING CT FOR ATTENUATION LIMITED AREA

Professional

Both

$407.86

Service Code	HCPCS 78814 26
Min. Negotiated Rate	$305.90
Max. Negotiated Rate	$305.90
Rate for Payer: Cash Price	$110.09
Rate for Payer: SOMOS CHP/HARP/Medicaid	$305.90
Rate for Payer: SOMOS Essential	$305.90

CHG PET IMAGING CT FOR ATTENUATION LIMITED AREA

Professional

Both

$6,319.08

Service Code	HCPCS 78814 TC
Min. Negotiated Rate	$4,739.31
Max. Negotiated Rate	$4,739.31
Rate for Payer: SOMOS CHP/HARP/Medicaid	$4,739.31
Rate for Payer: SOMOS Essential	$4,739.31

CHG PET IMAGING FOR CT ATTENUATION WHOLE BODY

Professional

Both

$6,319.08

Service Code	HCPCS 78816 TC
Min. Negotiated Rate	$4,739.31
Max. Negotiated Rate	$4,739.31
Rate for Payer: SOMOS CHP/HARP/Medicaid	$4,739.31
Rate for Payer: SOMOS Essential	$4,739.31

CHG PET IMAGING FOR CT ATTENUATION WHOLE BODY

Professional

Both

$6,771.70

Service Code	HCPCS 78816
Min. Negotiated Rate	$5,078.78
Max. Negotiated Rate	$5,078.78
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5,078.78
Rate for Payer: SOMOS Essential	$5,078.78

CHG PET IMAGING FOR CT ATTENUATION WHOLE BODY

Professional

Both

$452.62

Service Code	HCPCS 78816 26
Min. Negotiated Rate	$339.46
Max. Negotiated Rate	$339.46
Rate for Payer: Cash Price	$123.30
Rate for Payer: SOMOS CHP/HARP/Medicaid	$339.46
Rate for Payer: SOMOS Essential	$339.46

CHG PET IMAGING LIMITED AREA CHEST HEAD/NECK

Professional

Both

$278.29

Service Code	HCPCS 78811 26
Min. Negotiated Rate	$208.72
Max. Negotiated Rate	$208.72
Rate for Payer: Cash Price	$76.94
Rate for Payer: SOMOS CHP/HARP/Medicaid	$208.72
Rate for Payer: SOMOS Essential	$208.72

CHG PET IMAGING LIMITED AREA CHEST HEAD/NECK

Professional

Both

$5,910.28

Service Code	HCPCS 78811
Min. Negotiated Rate	$4,432.71
Max. Negotiated Rate	$4,432.71
Rate for Payer: SOMOS CHP/HARP/Medicaid	$4,432.71
Rate for Payer: SOMOS Essential	$4,432.71

CHG PET IMAGING LIMITED AREA CHEST HEAD/NECK

Professional

Both

$5,631.96

Service Code	HCPCS 78811 TC
Min. Negotiated Rate	$4,223.97
Max. Negotiated Rate	$4,223.97
Rate for Payer: SOMOS CHP/HARP/Medicaid	$4,223.97
Rate for Payer: SOMOS Essential	$4,223.97

CHG PET IMAGING SKULL BASE TO MID-THIGH

Professional

Both

$6,680.17

Service Code	HCPCS 78812
Min. Negotiated Rate	$5,010.13
Max. Negotiated Rate	$5,010.13
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5,010.13
Rate for Payer: SOMOS Essential	$5,010.13

CHG PET IMAGING SKULL BASE TO MID-THIGH

Professional

Both

$361.10

Service Code	HCPCS 78812 26
Min. Negotiated Rate	$270.82
Max. Negotiated Rate	$270.82
Rate for Payer: Cash Price	$97.30
Rate for Payer: SOMOS CHP/HARP/Medicaid	$270.82
Rate for Payer: SOMOS Essential	$270.82

CHG PET IMAGING SKULL BASE TO MID-THIGH

Professional

Both

$6,319.08

Service Code	HCPCS 78812 TC
Min. Negotiated Rate	$4,739.31
Max. Negotiated Rate	$4,739.31
Rate for Payer: SOMOS CHP/HARP/Medicaid	$4,739.31
Rate for Payer: SOMOS Essential	$4,739.31

CHG PET IMAGING WHOLE BODY

Professional

Both

$6,319.08

Service Code	HCPCS 78813 TC
Min. Negotiated Rate	$4,739.31
Max. Negotiated Rate	$4,739.31
Rate for Payer: SOMOS CHP/HARP/Medicaid	$4,739.31
Rate for Payer: SOMOS Essential	$4,739.31

CHG PET IMAGING WHOLE BODY

Professional

Both

$6,679.16

Service Code	HCPCS 78813
Min. Negotiated Rate	$5,009.37
Max. Negotiated Rate	$5,009.37
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5,009.37
Rate for Payer: SOMOS Essential	$5,009.37

Know your out-of-pocket cost for care.

All Charges