St. Barnabas Hospital

All Charges

Charge

Type

Price

STENT DIVERSION 6FR.

Facility IP

$515.48

Service Code	HCPCS C1877
Hospital Charge Code	64903070
Hospital Revenue Code	278
Min. Negotiated Rate	$257.74
Max. Negotiated Rate	$257.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$257.74
Rate for Payer: Hamaspik Choice Inc Medicare	$257.74

STENT EFX 5F .035 6X60

Facility OP

$2,900.00

Hospital Charge Code	64906745
Hospital Revenue Code	279
Min. Negotiated Rate	$1,015.00
Max. Negotiated Rate	$2,320.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,595.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,450.00
Rate for Payer: Aetna Government	$1,450.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,320.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,972.00
Rate for Payer: Group Health Inc Commercial	$1,450.00
Rate for Payer: Group Health Inc Medicare	$1,015.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,450.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,450.00

STENT ENDOPYLOTOMY

Facility OP

$200.00

Service Code	HCPCS C1877
Hospital Charge Code	64902539
Hospital Revenue Code	278
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$210.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$110.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$127.45
Rate for Payer: Aetna Government	$127.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$100.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$115.00
Rate for Payer: Fidelis Medicare Advantage	$210.00
Rate for Payer: Group Health Inc Commercial	$100.00
Rate for Payer: Group Health Inc Medicare	$70.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$100.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$130.00

STENT ENDOPYLOTOMY

Facility IP

$200.00

Service Code	HCPCS C1877
Hospital Charge Code	64902539
Hospital Revenue Code	278
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$100.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$100.00

STENT EPIC 6X100X120

Facility OP

$3,250.00

Service Code	HCPCS C1877
Hospital Charge Code	64902772
Hospital Revenue Code	278
Min. Negotiated Rate	$127.45
Max. Negotiated Rate	$3,412.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,787.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$127.45
Rate for Payer: Aetna Government	$127.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,625.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,868.75
Rate for Payer: Fidelis Medicare Advantage	$3,412.50
Rate for Payer: Group Health Inc Commercial	$1,625.00
Rate for Payer: Group Health Inc Medicare	$1,137.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,625.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,625.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,112.50

STENT EPIC 6X100X120

Facility IP

$3,250.00

Service Code	HCPCS C1877
Hospital Charge Code	64902772
Hospital Revenue Code	278
Min. Negotiated Rate	$1,625.00
Max. Negotiated Rate	$1,625.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,625.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,625.00

STENT FLUENCY 9 X 60 (FEM09060)

Facility OP

$2,095.00

Service Code	HCPCS C1768
Hospital Charge Code	64906422
Hospital Revenue Code	278
Min. Negotiated Rate	$322.77
Max. Negotiated Rate	$2,199.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,152.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,047.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,204.62
Rate for Payer: Fidelis Medicare Advantage	$2,199.75
Rate for Payer: Group Health Inc Commercial	$1,047.50
Rate for Payer: Group Health Inc Medicare	$733.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,047.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,047.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,361.75

STENT FLUENCY 9 X 60 (FEM09060)

Facility IP

$2,095.00

Service Code	HCPCS C1768
Hospital Charge Code	64906422
Hospital Revenue Code	278
Min. Negotiated Rate	$1,047.50
Max. Negotiated Rate	$1,047.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,047.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,047.50

STENT GLIDESHEATH

Facility IP

$183.75

Service Code	HCPCS C1874
Hospital Charge Code	64907350
Hospital Revenue Code	278
Min. Negotiated Rate	$91.88
Max. Negotiated Rate	$91.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$91.88
Rate for Payer: Hamaspik Choice Inc Medicare	$91.88

STENT GLIDESHEATH

Facility OP

$183.75

Service Code	HCPCS C1874
Hospital Charge Code	64907350
Hospital Revenue Code	278
Min. Negotiated Rate	$64.31
Max. Negotiated Rate	$265.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$101.06
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$265.52
Rate for Payer: Aetna Government	$265.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$91.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$105.66
Rate for Payer: Fidelis Medicare Advantage	$192.94
Rate for Payer: Group Health Inc Commercial	$91.88
Rate for Payer: Group Health Inc Medicare	$64.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$91.88
Rate for Payer: Hamaspik Choice Inc Medicare	$91.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$119.44

STENT GRAFT THRC TAG

Facility IP

$50,362.50

Service Code	HCPCS C1877
Hospital Charge Code	64907416
Hospital Revenue Code	278
Min. Negotiated Rate	$25,181.25
Max. Negotiated Rate	$25,181.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$25,181.25
Rate for Payer: Hamaspik Choice Inc Medicare	$25,181.25

STENT GRAFT THRC TAG

Facility OP

$50,362.50

Service Code	HCPCS C1877
Hospital Charge Code	64907416
Hospital Revenue Code	278
Min. Negotiated Rate	$127.45
Max. Negotiated Rate	$52,880.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$27,699.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$127.45
Rate for Payer: Aetna Government	$127.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$25,181.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$28,958.44
Rate for Payer: Fidelis Medicare Advantage	$52,880.62
Rate for Payer: Group Health Inc Commercial	$25,181.25
Rate for Payer: Group Health Inc Medicare	$17,626.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$25,181.25
Rate for Payer: Hamaspik Choice Inc Medicare	$25,181.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$32,735.62

STENT LIBERTE MONO 12MM 2.75

Facility OP

$1,800.00

Hospital Charge Code	65520110
Hospital Revenue Code	480
Min. Negotiated Rate	$630.00
Max. Negotiated Rate	$1,440.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$990.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$900.00
Rate for Payer: Aetna Government	$900.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,440.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,224.00
Rate for Payer: Group Health Inc Commercial	$900.00
Rate for Payer: Group Health Inc Medicare	$630.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$900.00
Rate for Payer: Hamaspik Choice Inc Medicare	$900.00

STENT PERC 4.8X24 W/O WIRE

Facility IP

$337.13

Service Code	HCPCS C1877
Hospital Charge Code	64901167
Hospital Revenue Code	278
Min. Negotiated Rate	$168.56
Max. Negotiated Rate	$168.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$168.56
Rate for Payer: Hamaspik Choice Inc Medicare	$168.56

STENT PERC 4.8X24 W/O WIRE

Facility OP

$337.13

Service Code	HCPCS C1877
Hospital Charge Code	64901167
Hospital Revenue Code	278
Min. Negotiated Rate	$118.00
Max. Negotiated Rate	$353.99
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$185.42
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$127.45
Rate for Payer: Aetna Government	$127.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$168.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$193.85
Rate for Payer: Fidelis Medicare Advantage	$353.99
Rate for Payer: Group Health Inc Commercial	$168.56
Rate for Payer: Group Health Inc Medicare	$118.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$168.56
Rate for Payer: Hamaspik Choice Inc Medicare	$168.56
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$219.13

STENT PERC PLUS 6X22 W/O WIRE

Facility IP

$303.75

Service Code	HCPCS C1877
Hospital Charge Code	64901169
Hospital Revenue Code	278
Min. Negotiated Rate	$151.88
Max. Negotiated Rate	$151.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$151.88
Rate for Payer: Hamaspik Choice Inc Medicare	$151.88

STENT PERC PLUS 6X22 W/O WIRE

Facility OP

$303.75

Service Code	HCPCS C1877
Hospital Charge Code	64901169
Hospital Revenue Code	278
Min. Negotiated Rate	$106.31
Max. Negotiated Rate	$318.94
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$167.06
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$127.45
Rate for Payer: Aetna Government	$127.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$151.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$174.66
Rate for Payer: Fidelis Medicare Advantage	$318.94
Rate for Payer: Group Health Inc Commercial	$151.88
Rate for Payer: Group Health Inc Medicare	$106.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$151.88
Rate for Payer: Hamaspik Choice Inc Medicare	$151.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$197.44

STENT PERCUFLEX 4.8FR24CM

Facility IP

$350.00

Service Code	HCPCS C2617
Hospital Charge Code	40209390
Hospital Revenue Code	278
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$175.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$175.00
Rate for Payer: Hamaspik Choice Inc Medicare	$175.00

STENT PERCUFLEX 4.8FR24CM

Facility OP

$350.00

Service Code	HCPCS C2617
Hospital Charge Code	40209390
Hospital Revenue Code	278
Min. Negotiated Rate	$10.14
Max. Negotiated Rate	$367.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$192.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10.14
Rate for Payer: Aetna Government	$10.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$175.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$201.25
Rate for Payer: Fidelis Medicare Advantage	$367.50
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
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$227.50

STENT PERCUFLEX 4.8FRX22CM

Facility IP

$350.00

Service Code	HCPCS C2617
Hospital Charge Code	40209387
Hospital Revenue Code	278
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$175.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$175.00
Rate for Payer: Hamaspik Choice Inc Medicare	$175.00

STENT PERCUFLEX 4.8FRX22CM

Facility OP

$350.00

Service Code	HCPCS C2617
Hospital Charge Code	40209387
Hospital Revenue Code	278
Min. Negotiated Rate	$10.14
Max. Negotiated Rate	$367.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$192.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10.14
Rate for Payer: Aetna Government	$10.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$175.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$201.25
Rate for Payer: Fidelis Medicare Advantage	$367.50
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
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$227.50

STENT PERCUFLEX 6.0X26

Facility IP

$238.00

Service Code	HCPCS C2617
Hospital Charge Code	40205344
Hospital Revenue Code	278
Min. Negotiated Rate	$119.00
Max. Negotiated Rate	$119.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$119.00
Rate for Payer: Hamaspik Choice Inc Medicare	$119.00

STENT PERCUFLEX 6.0X26

Facility OP

$238.00

Service Code	HCPCS C2617
Hospital Charge Code	40205344
Hospital Revenue Code	278
Min. Negotiated Rate	$10.14
Max. Negotiated Rate	$249.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$130.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10.14
Rate for Payer: Aetna Government	$10.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$119.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$136.85
Rate for Payer: Fidelis Medicare Advantage	$249.90
Rate for Payer: Group Health Inc Commercial	$119.00
Rate for Payer: Group Health Inc Medicare	$83.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$119.00
Rate for Payer: Hamaspik Choice Inc Medicare	$119.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$154.70

STENT PERC UURETERAL 4.8X26

Facility OP

$500.00

Service Code	HCPCS C1877
Hospital Charge Code	64901174
Hospital Revenue Code	278
Min. Negotiated Rate	$127.45
Max. Negotiated Rate	$525.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$275.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$127.45
Rate for Payer: Aetna Government	$127.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$250.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$287.50
Rate for Payer: Fidelis Medicare Advantage	$525.00
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$175.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$250.00
Rate for Payer: Hamaspik Choice Inc Medicare	$250.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$325.00

STENT PERC UURETERAL 4.8X26

Facility IP

$500.00

Service Code	HCPCS C1877
Hospital Charge Code	64901174
Hospital Revenue Code	278
Min. Negotiated Rate	$250.00
Max. Negotiated Rate	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$250.00
Rate for Payer: Hamaspik Choice Inc Medicare	$250.00

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