St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PR OUTFLOW TRACT AGMNTJ W/WO COMMISSUR/INFUND RESCJ

Professional

Both

$7,009.98

Service Code	HCPCS 33478
Min. Negotiated Rate	$5,257.48
Max. Negotiated Rate	$5,257.48
Rate for Payer: Cash Price	$1,865.43
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5,257.48
Rate for Payer: SOMOS Essential	$5,257.48

PR OUTPATIENT CARDIAC REHAB W/CONT ECG MONITORING

Professional

Both

$54.92

Service Code	HCPCS 93798
Min. Negotiated Rate	$41.19
Max. Negotiated Rate	$41.19
Rate for Payer: Cash Price	$14.95
Rate for Payer: SOMOS CHP/HARP/Medicaid	$41.19
Rate for Payer: SOMOS Essential	$41.19

PR OUTPATIENT CARDIAC REHAB W/O CONT ECG MONITOR

Professional

Both

$35.35

Service Code	HCPCS 93797
Min. Negotiated Rate	$26.51
Max. Negotiated Rate	$26.51
Rate for Payer: Cash Price	$9.65
Rate for Payer: SOMOS CHP/HARP/Medicaid	$26.51
Rate for Payer: SOMOS Essential	$26.51

PR OVARIAN CYSTECTOMY UNI/BI

Professional

Both

$3,379.71

Service Code	HCPCS 58925
Min. Negotiated Rate	$2,534.78
Max. Negotiated Rate	$2,534.78
Rate for Payer: Cash Price	$909.33
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,534.78
Rate for Payer: SOMOS Essential	$2,534.78

PROVE NASOLACRIMAL DUCT

Facility

$812.37

Service Code	HCPCS 68810
Hospital Charge Code	30307797
Hospital Revenue Code	510
Rate for Payer: Cash Price	$336.88

PROVE NASOLACRIMAL DUCT

Facility

$812.37

Service Code	HCPCS 68810
Hospital Charge Code	30307797
Hospital Revenue Code	510
Min. Negotiated Rate	$222.00
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,412.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$336.88
Rate for Payer: Aetna Government	$336.88
Rate for Payer: Affinity Essential Plan 1&2	$235.82
Rate for Payer: Affinity Essential Plan 3&4	$235.82
Rate for Payer: Affinity Medicaid/CHP/HARP	$235.82
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cash Price	$336.88
Rate for Payer: Cash Price	$336.88
Rate for Payer: Cash Price	$336.88
Rate for Payer: Cash Price	$336.88
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$336.88
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Elderplan Medicare Advantage	$336.88
Rate for Payer: Fidelis Essential Plan Aliesa	$286.35
Rate for Payer: Fidelis Essential Plan QHP	$299.82
Rate for Payer: Fidelis Medicare Advantage	$336.88
Rate for Payer: Fidelis Qualified Health Plan	$299.82
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	$406.18
Rate for Payer: Hamaspik Choice Inc Medicare	$336.88
Rate for Payer: Healthfirst Medicare Advantage	$286.35
Rate for Payer: Healthfirst QHP	$336.88
Rate for Payer: Humana Medicare	$343.62
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$336.88
Rate for Payer: Senior Whole Health Medicare Advantage	$336.88
Rate for Payer: United Healthcare Commercial	$222.00
Rate for Payer: United Healthcare Medicare Advantage	$336.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$336.88
Rate for Payer: Wellcare CHP/FHP/Medicaid	$269.50
Rate for Payer: Wellcare Medicare	$320.04

PROVISIONAL CROWN - NOT PROS REST

Facility

$318.94

Service Code	HCPCS D2799
Hospital Charge Code	42303296
Hospital Revenue Code	361
Min. Negotiated Rate	$159.47
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$175.42
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,018.19
Rate for Payer: Aetna Government	$1,018.19
Rate for Payer: Affinity Essential Plan 1&2	$712.73
Rate for Payer: Affinity Essential Plan 3&4	$712.73
Rate for Payer: Affinity Medicaid/CHP/HARP	$712.73
Rate for Payer: Brighton Health Commercial	$239.20
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Cash Price	$1,018.19
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,018.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Elderplan Medicare Advantage	$1,018.19
Rate for Payer: EmblemHealth Commercial	$1,018.19
Rate for Payer: Fidelis Essential Plan Aliesa	$865.46
Rate for Payer: Fidelis Essential Plan QHP	$906.19
Rate for Payer: Fidelis Medicare Advantage	$1,018.19
Rate for Payer: Fidelis Qualified Health Plan	$906.19
Rate for Payer: Group Health Inc Commercial	$1,018.19
Rate for Payer: Group Health Inc Medicare	$1,018.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$159.47
Rate for Payer: Hamaspik Choice Inc Medicare	$1,018.19
Rate for Payer: Healthfirst Medicare Advantage	$865.46
Rate for Payer: Healthfirst QHP	$1,018.19
Rate for Payer: Humana Medicare	$1,038.55
Rate for Payer: Senior Whole Health Medicare Advantage	$1,018.19
Rate for Payer: United Healthcare Medicare Advantage	$1,018.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,018.19
Rate for Payer: Wellcare CHP/FHP/Medicaid	$814.55
Rate for Payer: Wellcare Medicare	$967.28

PROVISIONAL CROWN - NOT PROS REST

Facility

$318.94

Service Code	HCPCS D2799
Hospital Charge Code	42303296
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,018.19

PROVISIONAL PONTIC

Facility

$250.00

Service Code	HCPCS D6253
Hospital Charge Code	42303443
Hospital Revenue Code	361
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$137.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$122.58
Rate for Payer: Aetna Government	$122.58
Rate for Payer: Brighton Health Commercial	$187.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
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

PROVISIONAL RETAINER CROWN

Facility

$250.00

Service Code	HCPCS D6793
Hospital Charge Code	42300744
Hospital Revenue Code	361
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$137.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$130.29
Rate for Payer: Aetna Government	$130.29
Rate for Payer: Brighton Health Commercial	$187.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
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

PROVISIONAL SPLINTING-EXTRACORONA

Facility

$350.00

Service Code	HCPCS D4321
Hospital Charge Code	42300910
Hospital Revenue Code	361
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$192.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$175.00
Rate for Payer: Aetna Government	$175.00
Rate for Payer: Brighton Health Commercial	$262.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Group Health Inc Commercial	$175.00
Rate for Payer: Group Health Inc Medicare	$122.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$175.00
Rate for Payer: Hamaspik Choice Inc Medicare	$175.00

PROVISIONAL SPLINTING-INTRACORONA

Facility

$381.00

Service Code	HCPCS D4320
Hospital Charge Code	42300905
Hospital Revenue Code	361
Min. Negotiated Rate	$133.35
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$209.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$190.50
Rate for Payer: Aetna Government	$190.50
Rate for Payer: Brighton Health Commercial	$285.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Group Health Inc Commercial	$190.50
Rate for Payer: Group Health Inc Medicare	$133.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$190.50
Rate for Payer: Hamaspik Choice Inc Medicare	$190.50

PROVOX VICE PROSTHESIS START KIT

Facility

$2,257.50

Hospital Charge Code	40109058
Hospital Revenue Code	270
Min. Negotiated Rate	$790.12
Max. Negotiated Rate	$1,806.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,241.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,128.75
Rate for Payer: Aetna Government	$1,128.75
Rate for Payer: Brighton Health Commercial	$1,693.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,806.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,535.10
Rate for Payer: Group Health Inc Commercial	$1,128.75
Rate for Payer: Group Health Inc Medicare	$790.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,128.75
Rate for Payer: Hamaspik Choice Inc Medicare	$1,128.75

PROX. HUMERAL NAIL 8 X 260

Facility

$4,249.38

Service Code	HCPCS C1713
Hospital Charge Code	64902888
Hospital Revenue Code	278
Min. Negotiated Rate	$2,124.69
Max. Negotiated Rate	$2,124.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,124.69
Rate for Payer: Hamaspik Choice Inc Medicare	$2,124.69

PROX. HUMERAL NAIL 8 X 260

Facility

$4,249.38

Service Code	HCPCS C1713
Hospital Charge Code	64902888
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$4,461.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,337.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$2,549.63
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,124.69
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,443.39
Rate for Payer: EmblemHealth Commercial	$2,124.69
Rate for Payer: Fidelis Medicare Advantage	$4,461.85
Rate for Payer: Group Health Inc Commercial	$2,124.69
Rate for Payer: Group Health Inc Medicare	$1,487.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,124.69
Rate for Payer: Hamaspik Choice Inc Medicare	$2,124.69
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,762.10

PROXIMAL HUMERUS NAIL

Facility

$6,464.00

Service Code	HCPCS C1713
Hospital Charge Code	40005863
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$6,787.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,555.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$3,878.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,232.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,716.80
Rate for Payer: EmblemHealth Commercial	$3,232.00
Rate for Payer: Fidelis Medicare Advantage	$6,787.20
Rate for Payer: Group Health Inc Commercial	$3,232.00
Rate for Payer: Group Health Inc Medicare	$2,262.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,232.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,232.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,201.60

PROXIMAL HUMERUS NAIL

Facility

$6,464.00

Service Code	HCPCS C1713
Hospital Charge Code	40005863
Hospital Revenue Code	278
Min. Negotiated Rate	$3,232.00
Max. Negotiated Rate	$3,232.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,232.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,232.00

PROXIMAL LATERAL TIBIA 2H LT

Facility

$1,908.20

Service Code	HCPCS C1713
Hospital Charge Code	40209945
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,003.61
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,049.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$1,144.92
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$954.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,097.22
Rate for Payer: EmblemHealth Commercial	$954.10
Rate for Payer: Fidelis Medicare Advantage	$2,003.61
Rate for Payer: Group Health Inc Commercial	$954.10
Rate for Payer: Group Health Inc Medicare	$667.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$954.10
Rate for Payer: Hamaspik Choice Inc Medicare	$954.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,240.33

PROXIMAL LATERAL TIBIA 2H LT

Facility

$1,908.20

Service Code	HCPCS C1713
Hospital Charge Code	40209945
Hospital Revenue Code	278
Min. Negotiated Rate	$954.10
Max. Negotiated Rate	$954.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$954.10
Rate for Payer: Hamaspik Choice Inc Medicare	$954.10

PROXIMAL LATERAL TIBIA-4HOLE LFT

Facility

$1,908.20

Service Code	HCPCS C1713
Hospital Charge Code	40201409
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,003.61
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,049.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$1,144.92
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$954.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,097.22
Rate for Payer: EmblemHealth Commercial	$954.10
Rate for Payer: Fidelis Medicare Advantage	$2,003.61
Rate for Payer: Group Health Inc Commercial	$954.10
Rate for Payer: Group Health Inc Medicare	$667.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$954.10
Rate for Payer: Hamaspik Choice Inc Medicare	$954.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,240.33

PROXIMAL LATERAL TIBIA-4HOLE LFT

Facility

$1,908.20

Service Code	HCPCS C1713
Hospital Charge Code	40201409
Hospital Revenue Code	278
Min. Negotiated Rate	$954.10
Max. Negotiated Rate	$954.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$954.10
Rate for Payer: Hamaspik Choice Inc Medicare	$954.10

PROXIMAL LATERAL TIBIA 4HOLE RT

Facility

$1,750.00

Service Code	HCPCS C1776
Hospital Charge Code	40209452
Hospital Revenue Code	278
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$875.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$875.00
Rate for Payer: Hamaspik Choice Inc Medicare	$875.00

PROXIMAL LATERAL TIBIA 4HOLE RT

Facility

$1,750.00

Service Code	HCPCS C1776
Hospital Charge Code	40209452
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$1,837.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$962.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$1,050.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$875.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,006.25
Rate for Payer: EmblemHealth Commercial	$875.00
Rate for Payer: Fidelis Medicare Advantage	$1,837.50
Rate for Payer: Group Health Inc Commercial	$875.00
Rate for Payer: Group Health Inc Medicare	$612.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$875.00
Rate for Payer: Hamaspik Choice Inc Medicare	$875.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,137.50

PROXIMAL LATERAL TIBIA PLATE F2

Facility

$6,585.00

Service Code	HCPCS C1713
Hospital Charge Code	64903313
Hospital Revenue Code	278
Min. Negotiated Rate	$3,292.50
Max. Negotiated Rate	$3,292.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,292.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3,292.50

PROXIMAL LATERAL TIBIA PLATE F2

Facility

$6,585.00

Service Code	HCPCS C1713
Hospital Charge Code	64903313
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$6,914.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,621.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$3,951.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,292.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,786.38
Rate for Payer: EmblemHealth Commercial	$3,292.50
Rate for Payer: Fidelis Medicare Advantage	$6,914.25
Rate for Payer: Group Health Inc Commercial	$3,292.50
Rate for Payer: Group Health Inc Medicare	$2,304.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,292.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3,292.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,280.25

Know your out-of-pocket cost for care.

All Charges