St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

LVL 2 EYE EXAM WITH PHOTOS

Facility

$1,470.80

Service Code	HCPCS 92230
Hospital Charge Code	30301194
Hospital Revenue Code	510
Min. Negotiated Rate	$173.89
Max. Negotiated Rate	$808.94
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$808.94
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$619.82
Rate for Payer: Aetna Government	$619.82
Rate for Payer: Affinity Essential Plan 1&2	$433.87
Rate for Payer: Affinity Essential Plan 3&4	$433.87
Rate for Payer: Affinity Medicaid/CHP/HARP	$433.87
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cash Price	$619.82
Rate for Payer: Cash Price	$619.82
Rate for Payer: Cash Price	$619.82
Rate for Payer: Cash Price	$619.82
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$619.82
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Elderplan Medicare Advantage	$619.82
Rate for Payer: Fidelis Essential Plan Aliesa	$526.85
Rate for Payer: Fidelis Essential Plan QHP	$551.64
Rate for Payer: Fidelis Medicare Advantage	$619.82
Rate for Payer: Fidelis Qualified Health Plan	$551.64
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$735.40
Rate for Payer: Hamaspik Choice Inc Medicare	$619.82
Rate for Payer: Healthfirst Medicare Advantage	$526.85
Rate for Payer: Healthfirst QHP	$619.82
Rate for Payer: Humana Medicare	$632.22
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$619.82
Rate for Payer: Senior Whole Health Medicare Advantage	$619.82
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Medicare Advantage	$619.82
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$619.82
Rate for Payer: Wellcare CHP/FHP/Medicaid	$495.86
Rate for Payer: Wellcare Medicare	$588.83

LW PROF 16H PLT W/0 BAR

Facility

$590.00

Service Code	HCPCS C1713
Hospital Charge Code	40202308
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$619.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$324.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$354.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$295.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$339.25
Rate for Payer: EmblemHealth Commercial	$295.00
Rate for Payer: Fidelis Medicare Advantage	$619.50
Rate for Payer: Group Health Inc Commercial	$295.00
Rate for Payer: Group Health Inc Medicare	$206.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$295.00
Rate for Payer: Hamaspik Choice Inc Medicare	$295.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$383.50

LW PROF 16H PLT W/0 BAR

Facility

$590.00

Service Code	HCPCS C1713
Hospital Charge Code	40202308
Hospital Revenue Code	278
Min. Negotiated Rate	$295.00
Max. Negotiated Rate	$295.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$295.00
Rate for Payer: Hamaspik Choice Inc Medicare	$295.00

LW PROF 2-HOLE PLATE 12MM BAR

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	40201221
Hospital Revenue Code	278
Min. Negotiated Rate	$124.00
Max. Negotiated Rate	$124.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$124.00
Rate for Payer: Hamaspik Choice Inc Medicare	$124.00

LW PROF 2-HOLE PLATE 12MM BAR

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	40201221
Hospital Revenue Code	278
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$260.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$136.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$148.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$124.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$142.60
Rate for Payer: EmblemHealth Commercial	$124.00
Rate for Payer: Fidelis Medicare Advantage	$260.40
Rate for Payer: Group Health Inc Commercial	$124.00
Rate for Payer: Group Health Inc Medicare	$86.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$124.00
Rate for Payer: Hamaspik Choice Inc Medicare	$124.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$161.20

LW PROF 2H PLT 16MM BAR

Facility

$250.00

Service Code	HCPCS C1713
Hospital Charge Code	40202309
Hospital Revenue Code	278
Min. Negotiated Rate	$125.00
Max. Negotiated Rate	$125.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$125.00
Rate for Payer: Hamaspik Choice Inc Medicare	$125.00

LW PROF 2H PLT 16MM BAR

Facility

$250.00

Service Code	HCPCS C1713
Hospital Charge Code	40202309
Hospital Revenue Code	278
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$262.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$137.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$150.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$125.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$143.75
Rate for Payer: EmblemHealth Commercial	$125.00
Rate for Payer: Fidelis Medicare Advantage	$262.50
Rate for Payer: Group Health Inc Commercial	$125.00
Rate for Payer: Group Health Inc Medicare	$87.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$125.00
Rate for Payer: Hamaspik Choice Inc Medicare	$125.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$162.50

LW PROF 2 X 2 BOX PLATE

Facility

$370.00

Service Code	HCPCS C1713
Hospital Charge Code	40201214
Hospital Revenue Code	278
Min. Negotiated Rate	$185.00
Max. Negotiated Rate	$185.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$185.00
Rate for Payer: Hamaspik Choice Inc Medicare	$185.00

LW PROF 2 X 2 BOX PLATE

Facility

$370.00

Service Code	HCPCS C1713
Hospital Charge Code	40201214
Hospital Revenue Code	278
Min. Negotiated Rate	$129.50
Max. Negotiated Rate	$388.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$203.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$222.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$185.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$212.75
Rate for Payer: EmblemHealth Commercial	$185.00
Rate for Payer: Fidelis Medicare Advantage	$388.50
Rate for Payer: Group Health Inc Commercial	$185.00
Rate for Payer: Group Health Inc Medicare	$129.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$185.00
Rate for Payer: Hamaspik Choice Inc Medicare	$185.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$240.50

LW PROF 4-HOLE PLATE,6MM BAR

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	40201223
Hospital Revenue Code	278
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$260.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$136.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$148.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$124.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$142.60
Rate for Payer: EmblemHealth Commercial	$124.00
Rate for Payer: Fidelis Medicare Advantage	$260.40
Rate for Payer: Group Health Inc Commercial	$124.00
Rate for Payer: Group Health Inc Medicare	$86.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$124.00
Rate for Payer: Hamaspik Choice Inc Medicare	$124.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$161.20

LW PROF 4-HOLE PLATE,6MM BAR

Facility

$248.00

Service Code	HCPCS C1713
Hospital Charge Code	40201223
Hospital Revenue Code	278
Min. Negotiated Rate	$124.00
Max. Negotiated Rate	$124.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$124.00
Rate for Payer: Hamaspik Choice Inc Medicare	$124.00

LW PROF 8H PLT W/O BAR

Facility

$334.00

Service Code	HCPCS C1713
Hospital Charge Code	40202311
Hospital Revenue Code	278
Min. Negotiated Rate	$167.00
Max. Negotiated Rate	$167.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$167.00
Rate for Payer: Hamaspik Choice Inc Medicare	$167.00

LW PROF 8H PLT W/O BAR

Facility

$334.00

Service Code	HCPCS C1713
Hospital Charge Code	40202311
Hospital Revenue Code	278
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$350.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$183.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$200.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$167.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$192.05
Rate for Payer: EmblemHealth Commercial	$167.00
Rate for Payer: Fidelis Medicare Advantage	$350.70
Rate for Payer: Group Health Inc Commercial	$167.00
Rate for Payer: Group Health Inc Medicare	$116.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$167.00
Rate for Payer: Hamaspik Choice Inc Medicare	$167.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$217.10

LW PROF BURRHOLE CVR,14MM WTAB

Facility

$466.00

Service Code	HCPCS C1713
Hospital Charge Code	40201193
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$489.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$256.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$279.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$233.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$267.95
Rate for Payer: EmblemHealth Commercial	$233.00
Rate for Payer: Fidelis Medicare Advantage	$489.30
Rate for Payer: Group Health Inc Commercial	$233.00
Rate for Payer: Group Health Inc Medicare	$163.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$233.00
Rate for Payer: Hamaspik Choice Inc Medicare	$233.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$302.90

LW PROF BURRHOLE CVR,14MM WTAB

Facility

$466.00

Service Code	HCPCS C1713
Hospital Charge Code	40201193
Hospital Revenue Code	278
Min. Negotiated Rate	$233.00
Max. Negotiated Rate	$233.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$233.00
Rate for Payer: Hamaspik Choice Inc Medicare	$233.00

LW PROF BURRHOLE CVR,20MM WTAB

Facility

$516.00

Service Code	HCPCS C1713
Hospital Charge Code	40201225
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$541.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$283.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$309.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$258.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$296.70
Rate for Payer: EmblemHealth Commercial	$258.00
Rate for Payer: Fidelis Medicare Advantage	$541.80
Rate for Payer: Group Health Inc Commercial	$258.00
Rate for Payer: Group Health Inc Medicare	$180.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$258.00
Rate for Payer: Hamaspik Choice Inc Medicare	$258.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$335.40

LW PROF BURRHOLE CVR,20MM WTAB

Facility

$516.00

Service Code	HCPCS C1713
Hospital Charge Code	40201225
Hospital Revenue Code	278
Min. Negotiated Rate	$258.00
Max. Negotiated Rate	$258.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$258.00
Rate for Payer: Hamaspik Choice Inc Medicare	$258.00

LW PROF BURRHOLE CVR,7MM W/TAB

Facility

$396.00

Service Code	HCPCS C1713
Hospital Charge Code	40201194
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$415.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$217.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$237.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$198.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$227.70
Rate for Payer: EmblemHealth Commercial	$198.00
Rate for Payer: Fidelis Medicare Advantage	$415.80
Rate for Payer: Group Health Inc Commercial	$198.00
Rate for Payer: Group Health Inc Medicare	$138.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$198.00
Rate for Payer: Hamaspik Choice Inc Medicare	$198.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$257.40

LW PROF BURRHOLE CVR,7MM W/TAB

Facility

$396.00

Service Code	HCPCS C1713
Hospital Charge Code	40201194
Hospital Revenue Code	278
Min. Negotiated Rate	$198.00
Max. Negotiated Rate	$198.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$198.00
Rate for Payer: Hamaspik Choice Inc Medicare	$198.00

LW PROF DBL-Y_PLATE. 6HOLE 8MM

Facility

$516.00

Service Code	HCPCS C1713
Hospital Charge Code	40201195
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$541.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$283.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$309.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$258.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$296.70
Rate for Payer: EmblemHealth Commercial	$258.00
Rate for Payer: Fidelis Medicare Advantage	$541.80
Rate for Payer: Group Health Inc Commercial	$258.00
Rate for Payer: Group Health Inc Medicare	$180.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$258.00
Rate for Payer: Hamaspik Choice Inc Medicare	$258.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$335.40

LW PROF DBL-Y_PLATE. 6HOLE 8MM

Facility

$516.00

Service Code	HCPCS C1713
Hospital Charge Code	40201195
Hospital Revenue Code	278
Min. Negotiated Rate	$258.00
Max. Negotiated Rate	$258.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$258.00
Rate for Payer: Hamaspik Choice Inc Medicare	$258.00

LW PROF EXRTA RIG 2-HL PLT 12MM

Facility

$210.00

Service Code	HCPCS C1713
Hospital Charge Code	40201196
Hospital Revenue Code	278
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$105.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$105.00
Rate for Payer: Hamaspik Choice Inc Medicare	$105.00

LW PROF EXRTA RIG 2-HL PLT 12MM

Facility

$210.00

Service Code	HCPCS C1713
Hospital Charge Code	40201196
Hospital Revenue Code	278
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$220.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$115.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$126.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$105.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$120.75
Rate for Payer: EmblemHealth Commercial	$105.00
Rate for Payer: Fidelis Medicare Advantage	$220.50
Rate for Payer: Group Health Inc Commercial	$105.00
Rate for Payer: Group Health Inc Medicare	$73.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$105.00
Rate for Payer: Hamaspik Choice Inc Medicare	$105.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$136.50

LW PROF GAP PLATE LARGE

Facility

$676.00

Service Code	HCPCS C1713
Hospital Charge Code	40201226
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$709.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$371.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$405.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$338.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$388.70
Rate for Payer: EmblemHealth Commercial	$338.00
Rate for Payer: Fidelis Medicare Advantage	$709.80
Rate for Payer: Group Health Inc Commercial	$338.00
Rate for Payer: Group Health Inc Medicare	$236.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$338.00
Rate for Payer: Hamaspik Choice Inc Medicare	$338.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$439.40

LW PROF GAP PLATE LARGE

Facility

$676.00

Service Code	HCPCS C1713
Hospital Charge Code	40201226
Hospital Revenue Code	278
Min. Negotiated Rate	$338.00
Max. Negotiated Rate	$338.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$338.00
Rate for Payer: Hamaspik Choice Inc Medicare	$338.00

Know your out-of-pocket cost for care.

All Charges