St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

MODULE INTUBATION RED B

Facility

$187.50

Hospital Charge Code	64903864
Hospital Revenue Code	270
Min. Negotiated Rate	$65.62
Max. Negotiated Rate	$150.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$103.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$93.75
Rate for Payer: Aetna Government	$93.75
Rate for Payer: Brighton Health Commercial	$140.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$150.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$127.50
Rate for Payer: Group Health Inc Commercial	$93.75
Rate for Payer: Group Health Inc Medicare	$65.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$93.75
Rate for Payer: Hamaspik Choice Inc Medicare	$93.75

MODULE INTUBATION WHITE B

Facility

$187.50

Hospital Charge Code	64903870
Hospital Revenue Code	270
Min. Negotiated Rate	$65.62
Max. Negotiated Rate	$150.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$103.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$93.75
Rate for Payer: Aetna Government	$93.75
Rate for Payer: Brighton Health Commercial	$140.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$150.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$127.50
Rate for Payer: Group Health Inc Commercial	$93.75
Rate for Payer: Group Health Inc Medicare	$65.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$93.75
Rate for Payer: Hamaspik Choice Inc Medicare	$93.75

MODULE INTUBATION YEL

Facility

$81.25

Hospital Charge Code	64903107
Hospital Revenue Code	270
Min. Negotiated Rate	$28.44
Max. Negotiated Rate	$65.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$44.69
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$40.62
Rate for Payer: Aetna Government	$40.62
Rate for Payer: Brighton Health Commercial	$60.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$65.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$55.25
Rate for Payer: Group Health Inc Commercial	$40.62
Rate for Payer: Group Health Inc Medicare	$28.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$40.62
Rate for Payer: Hamaspik Choice Inc Medicare	$40.62

MODULE IV DEL GREEN

Facility

$90.00

Hospital Charge Code	64903110
Hospital Revenue Code	270
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$72.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$49.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$45.00
Rate for Payer: Aetna Government	$45.00
Rate for Payer: Brighton Health Commercial	$67.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$72.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$61.20
Rate for Payer: Group Health Inc Commercial	$45.00
Rate for Payer: Group Health Inc Medicare	$31.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$45.00
Rate for Payer: Hamaspik Choice Inc Medicare	$45.00

MODULE I.V. DELIVERY BLUE

Facility

$90.00

Hospital Charge Code	64903268
Hospital Revenue Code	270
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$72.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$49.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$45.00
Rate for Payer: Aetna Government	$45.00
Rate for Payer: Brighton Health Commercial	$67.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$72.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$61.20
Rate for Payer: Group Health Inc Commercial	$45.00
Rate for Payer: Group Health Inc Medicare	$31.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$45.00
Rate for Payer: Hamaspik Choice Inc Medicare	$45.00

MODULE IV DELIVERY PUR

Facility

$90.00

Hospital Charge Code	64903088
Hospital Revenue Code	270
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$72.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$49.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$45.00
Rate for Payer: Aetna Government	$45.00
Rate for Payer: Brighton Health Commercial	$67.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$72.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$61.20
Rate for Payer: Group Health Inc Commercial	$45.00
Rate for Payer: Group Health Inc Medicare	$31.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$45.00
Rate for Payer: Hamaspik Choice Inc Medicare	$45.00

MODULE I.V. DELIVERY RED

Facility

$85.50

Hospital Charge Code	64903061
Hospital Revenue Code	270
Min. Negotiated Rate	$29.92
Max. Negotiated Rate	$68.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$47.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$42.75
Rate for Payer: Aetna Government	$42.75
Rate for Payer: Brighton Health Commercial	$64.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$68.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$58.14
Rate for Payer: Group Health Inc Commercial	$42.75
Rate for Payer: Group Health Inc Medicare	$29.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$42.75
Rate for Payer: Hamaspik Choice Inc Medicare	$42.75

MODULE I.V. DELIVERY WHITE

Facility

$90.00

Hospital Charge Code	64903265
Hospital Revenue Code	270
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$72.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$49.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$45.00
Rate for Payer: Aetna Government	$45.00
Rate for Payer: Brighton Health Commercial	$67.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$72.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$61.20
Rate for Payer: Group Health Inc Commercial	$45.00
Rate for Payer: Group Health Inc Medicare	$31.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$45.00
Rate for Payer: Hamaspik Choice Inc Medicare	$45.00

MODULE IV DEL YEL

Facility

$90.00

Hospital Charge Code	64903104
Hospital Revenue Code	270
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$72.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$49.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$45.00
Rate for Payer: Aetna Government	$45.00
Rate for Payer: Brighton Health Commercial	$67.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$72.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$61.20
Rate for Payer: Group Health Inc Commercial	$45.00
Rate for Payer: Group Health Inc Medicare	$31.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$45.00
Rate for Payer: Hamaspik Choice Inc Medicare	$45.00

MODULE IV ORANGE

Facility

$180.00

Hospital Charge Code	64903858
Hospital Revenue Code	270
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$144.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$99.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$90.00
Rate for Payer: Aetna Government	$90.00
Rate for Payer: Brighton Health Commercial	$135.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$144.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$122.40
Rate for Payer: Group Health Inc Commercial	$90.00
Rate for Payer: Group Health Inc Medicare	$63.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$90.00
Rate for Payer: Hamaspik Choice Inc Medicare	$90.00

MODULE IV YELLOW

Facility

$180.00

Hospital Charge Code	64903867
Hospital Revenue Code	270
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$144.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$99.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$90.00
Rate for Payer: Aetna Government	$90.00
Rate for Payer: Brighton Health Commercial	$135.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$144.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$122.40
Rate for Payer: Group Health Inc Commercial	$90.00
Rate for Payer: Group Health Inc Medicare	$63.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$90.00
Rate for Payer: Hamaspik Choice Inc Medicare	$90.00

MODULE OXYGEN DEL.GREEN

Facility

$32.50

Hospital Charge Code	64903112
Hospital Revenue Code	270
Min. Negotiated Rate	$11.38
Max. Negotiated Rate	$26.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$17.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.25
Rate for Payer: Aetna Government	$16.25
Rate for Payer: Brighton Health Commercial	$24.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$26.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$22.10
Rate for Payer: Group Health Inc Commercial	$16.25
Rate for Payer: Group Health Inc Medicare	$11.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.25
Rate for Payer: Hamaspik Choice Inc Medicare	$16.25

MODULE OXYGEN DELIVERY BLUE

Facility

$32.50

Hospital Charge Code	64903442
Hospital Revenue Code	270
Min. Negotiated Rate	$11.38
Max. Negotiated Rate	$26.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$17.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.25
Rate for Payer: Aetna Government	$16.25
Rate for Payer: Brighton Health Commercial	$24.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$26.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$22.10
Rate for Payer: Group Health Inc Commercial	$16.25
Rate for Payer: Group Health Inc Medicare	$11.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.25
Rate for Payer: Hamaspik Choice Inc Medicare	$16.25

MODULE OXYGEN DELIVERY PUR

Facility

$32.50

Hospital Charge Code	64903090
Hospital Revenue Code	270
Min. Negotiated Rate	$11.38
Max. Negotiated Rate	$26.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$17.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.25
Rate for Payer: Aetna Government	$16.25
Rate for Payer: Brighton Health Commercial	$24.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$26.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$22.10
Rate for Payer: Group Health Inc Commercial	$16.25
Rate for Payer: Group Health Inc Medicare	$11.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.25
Rate for Payer: Hamaspik Choice Inc Medicare	$16.25

MODULE OXYGEN DELIVERY WHITE

Facility

$32.50

Hospital Charge Code	64903444
Hospital Revenue Code	270
Min. Negotiated Rate	$11.38
Max. Negotiated Rate	$26.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$17.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.25
Rate for Payer: Aetna Government	$16.25
Rate for Payer: Brighton Health Commercial	$24.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$26.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$22.10
Rate for Payer: Group Health Inc Commercial	$16.25
Rate for Payer: Group Health Inc Medicare	$11.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.25
Rate for Payer: Hamaspik Choice Inc Medicare	$16.25

MODULE OXYGEN DEL. YEL

Facility

$32.50

Hospital Charge Code	64903105
Hospital Revenue Code	270
Min. Negotiated Rate	$11.38
Max. Negotiated Rate	$26.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$17.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.25
Rate for Payer: Aetna Government	$16.25
Rate for Payer: Brighton Health Commercial	$24.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$26.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$22.10
Rate for Payer: Group Health Inc Commercial	$16.25
Rate for Payer: Group Health Inc Medicare	$11.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.25
Rate for Payer: Hamaspik Choice Inc Medicare	$16.25

MODULES BROSELOW PROCEDURAL A

Facility

$2,300.00

Hospital Charge Code	64903437
Hospital Revenue Code	270
Min. Negotiated Rate	$805.00
Max. Negotiated Rate	$1,840.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,265.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,150.00
Rate for Payer: Aetna Government	$1,150.00
Rate for Payer: Brighton Health Commercial	$1,725.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,840.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,564.00
Rate for Payer: Group Health Inc Commercial	$1,150.00
Rate for Payer: Group Health Inc Medicare	$805.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,150.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,150.00

MODULES BROSELOW PROCEDURAL B

Facility

$2,300.00

Hospital Charge Code	64903881
Hospital Revenue Code	270
Min. Negotiated Rate	$805.00
Max. Negotiated Rate	$1,840.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,265.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,150.00
Rate for Payer: Aetna Government	$1,150.00
Rate for Payer: Brighton Health Commercial	$1,725.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,840.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,564.00
Rate for Payer: Group Health Inc Commercial	$1,150.00
Rate for Payer: Group Health Inc Medicare	$805.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,150.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,150.00

MOLD KNEE FEMORAL STGE 1 (432170)

Facility

$2,050.00

Service Code	HCPCS C1776
Hospital Charge Code	64906334
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$2,152.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,127.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$1,230.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,025.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,178.75
Rate for Payer: EmblemHealth Commercial	$1,025.00
Rate for Payer: Fidelis Medicare Advantage	$2,152.50
Rate for Payer: Group Health Inc Commercial	$1,025.00
Rate for Payer: Group Health Inc Medicare	$717.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,025.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,025.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,332.50

MOLD KNEE FEMORAL STGE 1 (432170)

Facility

$2,050.00

Service Code	HCPCS C1776
Hospital Charge Code	64906334
Hospital Revenue Code	278
Min. Negotiated Rate	$1,025.00
Max. Negotiated Rate	$1,025.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,025.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,025.00

MOLD KNEE TIBIAL STGE 1 (433175)

Facility

$1,460.00

Service Code	HCPCS C1776
Hospital Charge Code	64906333
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$1,533.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$803.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$876.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$730.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$839.50
Rate for Payer: EmblemHealth Commercial	$730.00
Rate for Payer: Fidelis Medicare Advantage	$1,533.00
Rate for Payer: Group Health Inc Commercial	$730.00
Rate for Payer: Group Health Inc Medicare	$511.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$730.00
Rate for Payer: Hamaspik Choice Inc Medicare	$730.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$949.00

MOLD KNEE TIBIAL STGE 1 (433175)

Facility

$1,460.00

Service Code	HCPCS C1776
Hospital Charge Code	64906333
Hospital Revenue Code	278
Min. Negotiated Rate	$730.00
Max. Negotiated Rate	$730.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$730.00
Rate for Payer: Hamaspik Choice Inc Medicare	$730.00

MOMENTUM ICD D120 B SCI

Facility

$31,375.00

Service Code	HCPCS C1722
Hospital Charge Code	66571444
Hospital Revenue Code	278
Min. Negotiated Rate	$3,988.80
Max. Negotiated Rate	$32,943.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$17,256.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,988.80
Rate for Payer: Aetna Government	$3,988.80
Rate for Payer: Brighton Health Commercial	$18,825.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$15,687.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$18,040.62
Rate for Payer: EmblemHealth Commercial	$15,687.50
Rate for Payer: Fidelis Medicare Advantage	$32,943.75
Rate for Payer: Group Health Inc Commercial	$15,687.50
Rate for Payer: Group Health Inc Medicare	$10,981.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$15,687.50
Rate for Payer: Hamaspik Choice Inc Medicare	$15,687.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$20,393.75

MOMENTUM ICD D120 B SCI

Facility

$31,375.00

Service Code	HCPCS C1722
Hospital Charge Code	66571444
Hospital Revenue Code	278
Min. Negotiated Rate	$15,687.50
Max. Negotiated Rate	$15,687.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$15,687.50
Rate for Payer: Hamaspik Choice Inc Medicare	$15,687.50

MOMETASONE FUROATE 110 MCG/ACT IN AEPB [188318]

Facility

$111.65

Service Code	NDC 78206011501
Hospital Charge Code	78206011501
Hospital Revenue Code	250
Min. Negotiated Rate	$39.08
Max. Negotiated Rate	$89.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$61.41
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$55.82
Rate for Payer: Aetna Government	$55.82
Rate for Payer: Brighton Health Commercial	$83.74
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$89.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$75.92
Rate for Payer: Group Health Inc Commercial	$55.82
Rate for Payer: Group Health Inc Medicare	$39.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$55.82
Rate for Payer: Hamaspik Choice Inc Medicare	$55.82
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$72.57

Know your out-of-pocket cost for care.

All Charges