St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

LUTONIX DRG CT BL 6MMX120MMX130MM

Facility

$3,500.00

Service Code	HCPCS C2623
Hospital Charge Code	40004749
Hospital Revenue Code	278
Min. Negotiated Rate	$1,225.00
Max. Negotiated Rate	$3,675.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,925.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,750.00
Rate for Payer: Aetna Government	$1,750.00
Rate for Payer: Brighton Health Commercial	$2,100.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,750.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,012.50
Rate for Payer: EmblemHealth Commercial	$1,750.00
Rate for Payer: Fidelis Medicare Advantage	$3,675.00
Rate for Payer: Group Health Inc Commercial	$1,750.00
Rate for Payer: Group Health Inc Medicare	$1,225.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,750.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,750.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,275.00

LUTONIX DRG CT BL 6MMX120MMX130MM

Facility

$3,500.00

Service Code	HCPCS C2623
Hospital Charge Code	40004749
Hospital Revenue Code	278
Min. Negotiated Rate	$1,750.00
Max. Negotiated Rate	$1,750.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,750.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,750.00

LUTONIX DRG CT BL 6MMX150MMX130MM

Facility

$3,800.00

Service Code	HCPCS C2623
Hospital Charge Code	40004750
Hospital Revenue Code	278
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$1,900.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,900.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,900.00

LUTONIX DRG CT BL 6MMX150MMX130MM

Facility

$3,800.00

Service Code	HCPCS C2623
Hospital Charge Code	40004750
Hospital Revenue Code	278
Min. Negotiated Rate	$1,330.00
Max. Negotiated Rate	$3,990.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,090.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,900.00
Rate for Payer: Aetna Government	$1,900.00
Rate for Payer: Brighton Health Commercial	$2,280.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,900.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,185.00
Rate for Payer: EmblemHealth Commercial	$1,900.00
Rate for Payer: Fidelis Medicare Advantage	$3,990.00
Rate for Payer: Group Health Inc Commercial	$1,900.00
Rate for Payer: Group Health Inc Medicare	$1,330.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,900.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,900.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,470.00

LUTONIX DRG CT BL 6MMX40MMX130MM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004745
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 6MMX40MMX130MM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004745
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LUTONIX DRG CT BL 6MMX40MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004807
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 6MMX40MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004807
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LUTONIX DRG CT BL 6MMX60MMX130MM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004746
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 6MMX60MMX130MM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004746
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LUTONIX DRG CT BL 6MMX60MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004808
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LUTONIX DRG CT BL 6MMX60MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004808
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 6MMX80MMX130MM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004747
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LUTONIX DRG CT BL 6MMX80MMX130MM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004747
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 6MMX80MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004809
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 6MMX80MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004809
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LUTONIX DRG CT BL 7MMX40MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004811
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LUTONIX DRG CT BL 7MMX40MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004811
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 7MMX60MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004812
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 7MMX60MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004812
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LVL 1 EYE EXAM WITH PHOTOS

Facility

$330.23

Service Code	HCPCS 92250 TC
Hospital Charge Code	30301195
Hospital Revenue Code	920
Rate for Payer: Cash Price	$147.72

LVL 1 EYE EXAM WITH PHOTOS

Facility

$330.23

Service Code	HCPCS 92250 TC
Hospital Charge Code	30301195
Hospital Revenue Code	920
Min. Negotiated Rate	$94.00
Max. Negotiated Rate	$264.18
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$181.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$147.72
Rate for Payer: Aetna Government	$147.72
Rate for Payer: Affinity Essential Plan 1&2	$103.40
Rate for Payer: Affinity Essential Plan 3&4	$103.40
Rate for Payer: Affinity Medicaid/CHP/HARP	$103.40
Rate for Payer: Brighton Health Commercial	$247.67
Rate for Payer: Cash Price	$147.72
Rate for Payer: Cash Price	$147.72
Rate for Payer: Cash Price	$147.72
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$147.72
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$264.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$224.56
Rate for Payer: Elderplan Medicare Advantage	$147.72
Rate for Payer: EmblemHealth Commercial	$147.72
Rate for Payer: Fidelis Essential Plan Aliesa	$125.56
Rate for Payer: Fidelis Essential Plan QHP	$131.47
Rate for Payer: Fidelis Medicare Advantage	$147.72
Rate for Payer: Fidelis Qualified Health Plan	$131.47
Rate for Payer: Group Health Inc Commercial	$147.72
Rate for Payer: Group Health Inc Medicare	$147.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$165.12
Rate for Payer: Hamaspik Choice Inc Medicare	$147.72
Rate for Payer: Healthfirst Medicare Advantage	$125.56
Rate for Payer: Healthfirst QHP	$147.72
Rate for Payer: Humana Medicare	$150.67
Rate for Payer: Senior Whole Health Medicare Advantage	$147.72
Rate for Payer: United Healthcare Commercial	$94.00
Rate for Payer: United Healthcare Medicare Advantage	$147.72
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$147.72
Rate for Payer: Wellcare CHP/FHP/Medicaid	$118.18
Rate for Payer: Wellcare Medicare	$140.33

LVL 1 EYE PHOTOGRAPHY

Facility

$166.60

Service Code	HCPCS 92285 TC
Hospital Charge Code	30301196
Hospital Revenue Code	920
Min. Negotiated Rate	$32.47
Max. Negotiated Rate	$133.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$91.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$46.38
Rate for Payer: Aetna Government	$46.38
Rate for Payer: Affinity Essential Plan 1&2	$32.47
Rate for Payer: Affinity Essential Plan 3&4	$32.47
Rate for Payer: Affinity Medicaid/CHP/HARP	$32.47
Rate for Payer: Brighton Health Commercial	$124.95
Rate for Payer: Cash Price	$46.38
Rate for Payer: Cash Price	$46.38
Rate for Payer: Cash Price	$46.38
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$46.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$133.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$113.29
Rate for Payer: Elderplan Medicare Advantage	$46.38
Rate for Payer: EmblemHealth Commercial	$46.38
Rate for Payer: Fidelis Essential Plan Aliesa	$39.42
Rate for Payer: Fidelis Essential Plan QHP	$41.28
Rate for Payer: Fidelis Medicare Advantage	$46.38
Rate for Payer: Fidelis Qualified Health Plan	$41.28
Rate for Payer: Group Health Inc Commercial	$46.38
Rate for Payer: Group Health Inc Medicare	$46.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$83.30
Rate for Payer: Hamaspik Choice Inc Medicare	$46.38
Rate for Payer: Healthfirst Medicare Advantage	$39.42
Rate for Payer: Healthfirst QHP	$46.38
Rate for Payer: Humana Medicare	$47.31
Rate for Payer: Senior Whole Health Medicare Advantage	$46.38
Rate for Payer: United Healthcare Commercial	$94.00
Rate for Payer: United Healthcare Medicare Advantage	$46.38
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$46.38
Rate for Payer: Wellcare CHP/FHP/Medicaid	$37.10
Rate for Payer: Wellcare Medicare	$44.06

LVL 1 EYE PHOTOGRAPHY

Facility

$166.60

Service Code	HCPCS 92285 TC
Hospital Charge Code	30301196
Hospital Revenue Code	920
Rate for Payer: Cash Price	$46.38

LVL 2 EYE EXAM WITH PHOTOS

Facility

$1,470.80

Service Code	HCPCS 92230
Hospital Charge Code	30301194
Hospital Revenue Code	510
Rate for Payer: Cash Price	$619.82

Know your out-of-pocket cost for care.

All Charges