St. Barnabas Hospital

All Charges

Charge

Type

Price

STENT PERIPH DIALYSIS SEGMENT

Facility OP

$30,010.30

Service Code	HCPCS 36903
Hospital Charge Code	40034505
Hospital Revenue Code	361
Min. Negotiated Rate	$341.29
Max. Negotiated Rate	$15,005.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$342.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$12,721.98
Rate for Payer: Aetna Government	$12,721.98
Rate for Payer: Cash Price	$12,721.98
Rate for Payer: Cash Price	$12,721.98
Rate for Payer: Cash Price	$12,721.98
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$12,721.98
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	$12,721.98
Rate for Payer: EmblemHealth Commercial	$12,721.98
Rate for Payer: Fidelis CHP/HARP/Medicaid	$341.29
Rate for Payer: Fidelis Essential Plan Aliesa	$10,813.68
Rate for Payer: Fidelis Essential Plan QHP	$11,322.56
Rate for Payer: Fidelis Medicare Advantage	$12,721.98
Rate for Payer: Fidelis Qualified Health Plan	$11,322.56
Rate for Payer: Group Health Inc Commercial	$12,721.98
Rate for Payer: Group Health Inc Medicare	$12,721.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$15,005.15
Rate for Payer: Hamaspik Choice Inc Medicare	$12,721.98
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$379.21
Rate for Payer: Healthfirst Medicare Advantage	$10,813.68
Rate for Payer: Healthfirst QHP	$12,721.98
Rate for Payer: Senior Whole Health Medicare Advantage	$12,721.98
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12,721.98
Rate for Payer: Wellcare CHP/FHP/Medicaid	$10,177.58
Rate for Payer: Wellcare Medicare	$12,085.88

STENT PERIPH DRG EL A

Facility OP

$2,937.50

Service Code	HCPCS C1874
Hospital Charge Code	64904139
Hospital Revenue Code	278
Min. Negotiated Rate	$265.52
Max. Negotiated Rate	$3,084.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,615.62
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	$1,468.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,689.06
Rate for Payer: Fidelis Medicare Advantage	$3,084.38
Rate for Payer: Group Health Inc Commercial	$1,468.75
Rate for Payer: Group Health Inc Medicare	$1,028.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,468.75
Rate for Payer: Hamaspik Choice Inc Medicare	$1,468.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,909.38

STENT PERIPH DRG EL A

Facility IP

$2,937.50

Service Code	HCPCS C1874
Hospital Charge Code	64904139
Hospital Revenue Code	278
Min. Negotiated Rate	$1,468.75
Max. Negotiated Rate	$1,468.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,468.75
Rate for Payer: Hamaspik Choice Inc Medicare	$1,468.75

STENT PERIPH DRG EL B

Facility OP

$4,487.50

Service Code	HCPCS C1874
Hospital Charge Code	64904141
Hospital Revenue Code	278
Min. Negotiated Rate	$265.52
Max. Negotiated Rate	$4,711.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,468.12
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	$2,243.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,580.31
Rate for Payer: Fidelis Medicare Advantage	$4,711.88
Rate for Payer: Group Health Inc Commercial	$2,243.75
Rate for Payer: Group Health Inc Medicare	$1,570.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,243.75
Rate for Payer: Hamaspik Choice Inc Medicare	$2,243.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,916.88

STENT PERIPH DRG EL B

Facility IP

$4,487.50

Service Code	HCPCS C1874
Hospital Charge Code	64904141
Hospital Revenue Code	278
Min. Negotiated Rate	$2,243.75
Max. Negotiated Rate	$2,243.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,243.75
Rate for Payer: Hamaspik Choice Inc Medicare	$2,243.75

STENT PERIPH EVFLX 035

Facility OP

$1,420.00

Hospital Charge Code	64906370
Hospital Revenue Code	279
Min. Negotiated Rate	$497.00
Max. Negotiated Rate	$1,136.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$781.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$710.00
Rate for Payer: Aetna Government	$710.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,136.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$965.60
Rate for Payer: Group Health Inc Commercial	$710.00
Rate for Payer: Group Health Inc Medicare	$497.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$710.00
Rate for Payer: Hamaspik Choice Inc Medicare	$710.00

STENT POLARIS 5FR X 24CM

Facility OP

$442.50

Service Code	HCPCS C1877
Hospital Charge Code	64901281
Hospital Revenue Code	278
Min. Negotiated Rate	$127.45
Max. Negotiated Rate	$464.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$243.38
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	$221.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$254.44
Rate for Payer: Fidelis Medicare Advantage	$464.62
Rate for Payer: Group Health Inc Commercial	$221.25
Rate for Payer: Group Health Inc Medicare	$154.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$221.25
Rate for Payer: Hamaspik Choice Inc Medicare	$221.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$287.62

STENT POLARIS 5FR X 24CM

Facility IP

$442.50

Service Code	HCPCS C1877
Hospital Charge Code	64901281
Hospital Revenue Code	278
Min. Negotiated Rate	$221.25
Max. Negotiated Rate	$221.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$221.25
Rate for Payer: Hamaspik Choice Inc Medicare	$221.25

STENT POLARIS 6X26

Facility OP

$358.75

Service Code	HCPCS C1877
Hospital Charge Code	64903730
Hospital Revenue Code	278
Min. Negotiated Rate	$125.56
Max. Negotiated Rate	$376.69
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$197.31
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	$179.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$206.28
Rate for Payer: Fidelis Medicare Advantage	$376.69
Rate for Payer: Group Health Inc Commercial	$179.38
Rate for Payer: Group Health Inc Medicare	$125.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$179.38
Rate for Payer: Hamaspik Choice Inc Medicare	$179.38
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$233.19

STENT POLARIS 6X26

Facility IP

$358.75

Service Code	HCPCS C1877
Hospital Charge Code	64903730
Hospital Revenue Code	278
Min. Negotiated Rate	$179.38
Max. Negotiated Rate	$179.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$179.38
Rate for Payer: Hamaspik Choice Inc Medicare	$179.38

STENT POLARIS LOOP URET W/O WIRE

Facility IP

$447.50

Service Code	HCPCS C1877
Hospital Charge Code	64901361
Hospital Revenue Code	278
Min. Negotiated Rate	$223.75
Max. Negotiated Rate	$223.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$223.75
Rate for Payer: Hamaspik Choice Inc Medicare	$223.75

STENT POLARIS LOOP URET W/O WIRE

Facility OP

$447.50

Service Code	HCPCS C1877
Hospital Charge Code	64901361
Hospital Revenue Code	278
Min. Negotiated Rate	$127.45
Max. Negotiated Rate	$469.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$246.12
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	$223.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$257.31
Rate for Payer: Fidelis Medicare Advantage	$469.88
Rate for Payer: Group Health Inc Commercial	$223.75
Rate for Payer: Group Health Inc Medicare	$156.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$223.75
Rate for Payer: Hamaspik Choice Inc Medicare	$223.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$290.88

STENT POLARIS ULTRA 5F X 20CM

Facility OP

$562.50

Service Code	HCPCS C1877
Hospital Charge Code	64901824
Hospital Revenue Code	278
Min. Negotiated Rate	$127.45
Max. Negotiated Rate	$590.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$309.38
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	$281.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$323.44
Rate for Payer: Fidelis Medicare Advantage	$590.62
Rate for Payer: Group Health Inc Commercial	$281.25
Rate for Payer: Group Health Inc Medicare	$196.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$281.25
Rate for Payer: Hamaspik Choice Inc Medicare	$281.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$365.62

STENT POLARIS ULTRA 5F X 20CM

Facility IP

$562.50

Service Code	HCPCS C1877
Hospital Charge Code	64901824
Hospital Revenue Code	278
Min. Negotiated Rate	$281.25
Max. Negotiated Rate	$281.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$281.25
Rate for Payer: Hamaspik Choice Inc Medicare	$281.25

STENT POLARIS ULTRA 5F X 26CM

Facility OP

$380.63

Service Code	HCPCS C1877
Hospital Charge Code	64901826
Hospital Revenue Code	278
Min. Negotiated Rate	$127.45
Max. Negotiated Rate	$399.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$209.35
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	$190.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$218.86
Rate for Payer: Fidelis Medicare Advantage	$399.66
Rate for Payer: Group Health Inc Commercial	$190.32
Rate for Payer: Group Health Inc Medicare	$133.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$190.32
Rate for Payer: Hamaspik Choice Inc Medicare	$190.32
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$247.41

STENT POLARIS ULTRA 5F X 26CM

Facility IP

$380.63

Service Code	HCPCS C1877
Hospital Charge Code	64901826
Hospital Revenue Code	278
Min. Negotiated Rate	$190.32
Max. Negotiated Rate	$190.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$190.32
Rate for Payer: Hamaspik Choice Inc Medicare	$190.32

STENT POLARIS ULTRA 5F X 28CM

Facility IP

$562.50

Service Code	HCPCS C1877
Hospital Charge Code	64901827
Hospital Revenue Code	278
Min. Negotiated Rate	$281.25
Max. Negotiated Rate	$281.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$281.25
Rate for Payer: Hamaspik Choice Inc Medicare	$281.25

STENT POLARIS ULTRA 5F X 28CM

Facility OP

$562.50

Service Code	HCPCS C1877
Hospital Charge Code	64901827
Hospital Revenue Code	278
Min. Negotiated Rate	$127.45
Max. Negotiated Rate	$590.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$309.38
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	$281.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$323.44
Rate for Payer: Fidelis Medicare Advantage	$590.62
Rate for Payer: Group Health Inc Commercial	$281.25
Rate for Payer: Group Health Inc Medicare	$196.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$281.25
Rate for Payer: Hamaspik Choice Inc Medicare	$281.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$365.62

STENT POLARIS ULTRA 6FR30CM

Facility OP

$324.52

Hospital Charge Code	64906719
Hospital Revenue Code	279
Min. Negotiated Rate	$113.58
Max. Negotiated Rate	$259.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$178.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$162.26
Rate for Payer: Aetna Government	$162.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$259.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$220.67
Rate for Payer: Group Health Inc Commercial	$162.26
Rate for Payer: Group Health Inc Medicare	$113.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$162.26
Rate for Payer: Hamaspik Choice Inc Medicare	$162.26

STENT POLARIS ULTRA 6F X 20CM

Facility OP

$358.75

Service Code	HCPCS C1877
Hospital Charge Code	64902700
Hospital Revenue Code	278
Min. Negotiated Rate	$125.56
Max. Negotiated Rate	$376.69
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$197.31
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	$179.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$206.28
Rate for Payer: Fidelis Medicare Advantage	$376.69
Rate for Payer: Group Health Inc Commercial	$179.38
Rate for Payer: Group Health Inc Medicare	$125.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$179.38
Rate for Payer: Hamaspik Choice Inc Medicare	$179.38
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$233.19

STENT POLARIS ULTRA 6F X 20CM

Facility IP

$358.75

Service Code	HCPCS C1877
Hospital Charge Code	64902700
Hospital Revenue Code	278
Min. Negotiated Rate	$179.38
Max. Negotiated Rate	$179.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$179.38
Rate for Payer: Hamaspik Choice Inc Medicare	$179.38

STENT POLARIS ULTRA 6F X 22CM

Facility IP

$358.75

Service Code	HCPCS C1877
Hospital Charge Code	64902503
Hospital Revenue Code	278
Min. Negotiated Rate	$179.38
Max. Negotiated Rate	$179.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$179.38
Rate for Payer: Hamaspik Choice Inc Medicare	$179.38

STENT POLARIS ULTRA 6F X 22CM

Facility OP

$358.75

Service Code	HCPCS C1877
Hospital Charge Code	64902503
Hospital Revenue Code	278
Min. Negotiated Rate	$125.56
Max. Negotiated Rate	$376.69
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$197.31
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	$179.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$206.28
Rate for Payer: Fidelis Medicare Advantage	$376.69
Rate for Payer: Group Health Inc Commercial	$179.38
Rate for Payer: Group Health Inc Medicare	$125.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$179.38
Rate for Payer: Hamaspik Choice Inc Medicare	$179.38
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$233.19

STENT POLARIS ULTRA 6F X 24CM

Facility OP

$358.75

Service Code	HCPCS C1877
Hospital Charge Code	64902054
Hospital Revenue Code	278
Min. Negotiated Rate	$125.56
Max. Negotiated Rate	$376.69
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$197.31
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	$179.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$206.28
Rate for Payer: Fidelis Medicare Advantage	$376.69
Rate for Payer: Group Health Inc Commercial	$179.38
Rate for Payer: Group Health Inc Medicare	$125.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$179.38
Rate for Payer: Hamaspik Choice Inc Medicare	$179.38
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$233.19

STENT POLARIS ULTRA 6F X 24CM

Facility IP

$358.75

Service Code	HCPCS C1877
Hospital Charge Code	64902054
Hospital Revenue Code	278
Min. Negotiated Rate	$179.38
Max. Negotiated Rate	$179.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$179.38
Rate for Payer: Hamaspik Choice Inc Medicare	$179.38

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