St. Barnabas Hospital

All Charges

Charge

Type

Price

STENT RX 10 X 10CM BOSTON

Facility IP

$456.03

Service Code	HCPCS C1877
Hospital Charge Code	64901316
Hospital Revenue Code	278
Min. Negotiated Rate	$228.02
Max. Negotiated Rate	$228.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$228.02
Rate for Payer: Hamaspik Choice Inc Medicare	$228.02

STENT RX 10 X 10CM BOSTON

Facility OP

$456.03

Service Code	HCPCS C1877
Hospital Charge Code	64901316
Hospital Revenue Code	278
Min. Negotiated Rate	$127.45
Max. Negotiated Rate	$478.83
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$250.82
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	$228.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$262.22
Rate for Payer: Fidelis Medicare Advantage	$478.83
Rate for Payer: Group Health Inc Commercial	$228.02
Rate for Payer: Group Health Inc Medicare	$159.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$228.02
Rate for Payer: Hamaspik Choice Inc Medicare	$228.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$296.42

STENT RX 10 X 5CM BOSTON

Facility IP

$372.50

Service Code	HCPCS C1877
Hospital Charge Code	64901315
Hospital Revenue Code	278
Min. Negotiated Rate	$186.25
Max. Negotiated Rate	$186.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$186.25
Rate for Payer: Hamaspik Choice Inc Medicare	$186.25

STENT RX 10 X 5CM BOSTON

Facility OP

$372.50

Service Code	HCPCS C1877
Hospital Charge Code	64901315
Hospital Revenue Code	278
Min. Negotiated Rate	$127.45
Max. Negotiated Rate	$391.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$204.88
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	$186.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$214.19
Rate for Payer: Fidelis Medicare Advantage	$391.12
Rate for Payer: Group Health Inc Commercial	$186.25
Rate for Payer: Group Health Inc Medicare	$130.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$186.25
Rate for Payer: Hamaspik Choice Inc Medicare	$186.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$242.12

STENT RX 10X5CM BOSTON

Facility OP

$300.00

Service Code	HCPCS C1874
Hospital Charge Code	40200997
Hospital Revenue Code	278
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$315.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$165.00
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	$150.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$172.50
Rate for Payer: Fidelis Medicare Advantage	$315.00
Rate for Payer: Group Health Inc Commercial	$150.00
Rate for Payer: Group Health Inc Medicare	$105.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$150.00
Rate for Payer: Hamaspik Choice Inc Medicare	$150.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$195.00

STENT RX 10X5CM BOSTON

Facility IP

$300.00

Service Code	HCPCS C1874
Hospital Charge Code	40200997
Hospital Revenue Code	278
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$150.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$150.00
Rate for Payer: Hamaspik Choice Inc Medicare	$150.00

STENT RX 7 X 10CM BOSTON

Facility OP

$456.03

Service Code	HCPCS C1877
Hospital Charge Code	64901318
Hospital Revenue Code	278
Min. Negotiated Rate	$127.45
Max. Negotiated Rate	$478.83
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$250.82
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	$228.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$262.22
Rate for Payer: Fidelis Medicare Advantage	$478.83
Rate for Payer: Group Health Inc Commercial	$228.02
Rate for Payer: Group Health Inc Medicare	$159.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$228.02
Rate for Payer: Hamaspik Choice Inc Medicare	$228.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$296.42

STENT RX 7 X 10CM BOSTON

Facility IP

$456.03

Service Code	HCPCS C1877
Hospital Charge Code	64901318
Hospital Revenue Code	278
Min. Negotiated Rate	$228.02
Max. Negotiated Rate	$228.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$228.02
Rate for Payer: Hamaspik Choice Inc Medicare	$228.02

STENT RX 7X10CM BOSTON

Facility OP

$222.00

Service Code	HCPCS C1874
Hospital Charge Code	40200998
Hospital Revenue Code	278
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$265.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$122.10
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	$111.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$127.65
Rate for Payer: Fidelis Medicare Advantage	$233.10
Rate for Payer: Group Health Inc Commercial	$111.00
Rate for Payer: Group Health Inc Medicare	$77.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$111.00
Rate for Payer: Hamaspik Choice Inc Medicare	$111.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$144.30

STENT RX 7X10CM BOSTON

Facility IP

$222.00

Service Code	HCPCS C1874
Hospital Charge Code	40200998
Hospital Revenue Code	278
Min. Negotiated Rate	$111.00
Max. Negotiated Rate	$111.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$111.00
Rate for Payer: Hamaspik Choice Inc Medicare	$111.00

STENT RX 7X5CM BOSTON

Facility IP

$240.00

Service Code	HCPCS C1874
Hospital Charge Code	40200999
Hospital Revenue Code	278
Min. Negotiated Rate	$120.00
Max. Negotiated Rate	$120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$120.00
Rate for Payer: Hamaspik Choice Inc Medicare	$120.00

STENT RX 7X5CM BOSTON

Facility OP

$240.00

Service Code	HCPCS C1874
Hospital Charge Code	40200999
Hospital Revenue Code	278
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$265.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$132.00
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	$120.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$138.00
Rate for Payer: Fidelis Medicare Advantage	$252.00
Rate for Payer: Group Health Inc Commercial	$120.00
Rate for Payer: Group Health Inc Medicare	$84.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$120.00
Rate for Payer: Hamaspik Choice Inc Medicare	$120.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$156.00

STENT SYSTEM AG 23

Facility OP

$9,710.15

Hospital Charge Code	64907515
Hospital Revenue Code	279
Min. Negotiated Rate	$3,398.55
Max. Negotiated Rate	$7,768.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,340.58
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4,855.08
Rate for Payer: Aetna Government	$4,855.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7,768.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$6,602.90
Rate for Payer: Group Health Inc Commercial	$4,855.08
Rate for Payer: Group Health Inc Medicare	$3,398.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,855.08
Rate for Payer: Hamaspik Choice Inc Medicare	$4,855.08

STENT SYSTEM VASC 6 X 40

Facility OP

$3,375.00

Service Code	HCPCS C1876
Hospital Charge Code	64902941
Hospital Revenue Code	278
Min. Negotiated Rate	$398.18
Max. Negotiated Rate	$3,543.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,856.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$398.18
Rate for Payer: Aetna Government	$398.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,687.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,940.62
Rate for Payer: Fidelis Medicare Advantage	$3,543.75
Rate for Payer: Group Health Inc Commercial	$1,687.50
Rate for Payer: Group Health Inc Medicare	$1,181.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,687.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,687.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,193.75

STENT SYSTEM VASC 6 X 40

Facility IP

$3,375.00

Service Code	HCPCS C1876
Hospital Charge Code	64902941
Hospital Revenue Code	278
Min. Negotiated Rate	$1,687.50
Max. Negotiated Rate	$1,687.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,687.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,687.50

STENT ULTRA URETERAL 5 FR X 22

Facility OP

$350.00

Service Code	HCPCS C2617
Hospital Charge Code	40209617
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 ULTRA URETERAL 5 FR X 22

Facility IP

$350.00

Service Code	HCPCS C2617
Hospital Charge Code	40209617
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 ULTRA URETERAL 5FRX22

Facility IP

$350.00

Service Code	HCPCS C2617
Hospital Charge Code	40209680
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 ULTRA URETERAL 5FRX22

Facility OP

$350.00

Service Code	HCPCS C2617
Hospital Charge Code	40209680
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 ULTRA URETERAL 5 FR X 24

Facility OP

$350.00

Service Code	HCPCS C2617
Hospital Charge Code	40209618
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 ULTRA URETERAL 5 FR X 24

Facility IP

$350.00

Service Code	HCPCS C2617
Hospital Charge Code	40209618
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 ULTRA URETERAL 5FRX24

Facility OP

$350.00

Service Code	HCPCS C2617
Hospital Charge Code	40209681
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 ULTRA URETERAL 5FRX24

Facility IP

$350.00

Service Code	HCPCS C2617
Hospital Charge Code	40209681
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 URETERAL 5FRX20CM

Facility IP

$350.00

Service Code	HCPCS C2617
Hospital Charge Code	40209682
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 URETERAL 5FRX20CM

Facility OP

$350.00

Service Code	HCPCS C2617
Hospital Charge Code	40209682
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

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