St. Barnabas Hospital

All Charges

Charge

Type

Price

STENT URETERAL 6FRX28CM

Facility OP

$350.00

Service Code	HCPCS C2617
Hospital Charge Code	40209690
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 URETERAL 7FRX20CM

Facility IP

$338.00

Service Code	HCPCS C2617
Hospital Charge Code	40209691
Hospital Revenue Code	278
Min. Negotiated Rate	$169.00
Max. Negotiated Rate	$169.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$169.00
Rate for Payer: Hamaspik Choice Inc Medicare	$169.00

STENT URETERAL 7FRX20CM

Facility OP

$338.00

Service Code	HCPCS C2617
Hospital Charge Code	40209691
Hospital Revenue Code	278
Min. Negotiated Rate	$10.14
Max. Negotiated Rate	$354.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$185.90
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	$169.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$194.35
Rate for Payer: Fidelis Medicare Advantage	$354.90
Rate for Payer: Group Health Inc Commercial	$169.00
Rate for Payer: Group Health Inc Medicare	$118.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$169.00
Rate for Payer: Hamaspik Choice Inc Medicare	$169.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$219.70

STENT URETERAL 7FRX22CM

Facility OP

$390.00

Service Code	HCPCS C2617
Hospital Charge Code	40209692
Hospital Revenue Code	278
Min. Negotiated Rate	$10.14
Max. Negotiated Rate	$409.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$214.50
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	$195.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$224.25
Rate for Payer: Fidelis Medicare Advantage	$409.50
Rate for Payer: Group Health Inc Commercial	$195.00
Rate for Payer: Group Health Inc Medicare	$136.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$195.00
Rate for Payer: Hamaspik Choice Inc Medicare	$195.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$253.50

STENT URETERAL 7FRX22CM

Facility IP

$390.00

Service Code	HCPCS C2617
Hospital Charge Code	40209692
Hospital Revenue Code	278
Min. Negotiated Rate	$195.00
Max. Negotiated Rate	$195.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$195.00
Rate for Payer: Hamaspik Choice Inc Medicare	$195.00

STENT URETERAL 7FRX24CM

Facility OP

$350.00

Service Code	HCPCS C2617
Hospital Charge Code	40209693
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 URETERAL 7FRX24CM

Facility IP

$350.00

Service Code	HCPCS C2617
Hospital Charge Code	40209693
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 7FRX26CM

Facility IP

$390.00

Service Code	HCPCS C2617
Hospital Charge Code	40209694
Hospital Revenue Code	278
Min. Negotiated Rate	$195.00
Max. Negotiated Rate	$195.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$195.00
Rate for Payer: Hamaspik Choice Inc Medicare	$195.00

STENT URETERAL 7FRX26CM

Facility OP

$390.00

Service Code	HCPCS C2617
Hospital Charge Code	40209694
Hospital Revenue Code	278
Min. Negotiated Rate	$10.14
Max. Negotiated Rate	$409.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$214.50
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	$195.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$224.25
Rate for Payer: Fidelis Medicare Advantage	$409.50
Rate for Payer: Group Health Inc Commercial	$195.00
Rate for Payer: Group Health Inc Medicare	$136.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$195.00
Rate for Payer: Hamaspik Choice Inc Medicare	$195.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$253.50

STENT URETERAL 7FRX28CM

Facility IP

$258.00

Service Code	HCPCS C2617
Hospital Charge Code	40209695
Hospital Revenue Code	278
Min. Negotiated Rate	$129.00
Max. Negotiated Rate	$129.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$129.00
Rate for Payer: Hamaspik Choice Inc Medicare	$129.00

STENT URETERAL 7FRX28CM

Facility OP

$258.00

Service Code	HCPCS C2617
Hospital Charge Code	40209695
Hospital Revenue Code	278
Min. Negotiated Rate	$10.14
Max. Negotiated Rate	$270.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$141.90
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	$129.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$148.35
Rate for Payer: Fidelis Medicare Advantage	$270.90
Rate for Payer: Group Health Inc Commercial	$129.00
Rate for Payer: Group Health Inc Medicare	$90.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$129.00
Rate for Payer: Hamaspik Choice Inc Medicare	$129.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$167.70

STENT URETERAL DOUBLE PIGT

Facility OP

$358.75

Hospital Charge Code	64905746
Hospital Revenue Code	270
Min. Negotiated Rate	$125.56
Max. Negotiated Rate	$287.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$197.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$179.38
Rate for Payer: Aetna Government	$179.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$287.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$243.95
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

STENT URETERAL POLARIS 6FRX20CM

Facility IP

$467.50

Service Code	HCPCS C1877
Hospital Charge Code	64901271
Hospital Revenue Code	278
Min. Negotiated Rate	$233.75
Max. Negotiated Rate	$233.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$233.75
Rate for Payer: Hamaspik Choice Inc Medicare	$233.75

STENT URETERAL POLARIS 6FRX20CM

Facility OP

$467.50

Service Code	HCPCS C1877
Hospital Charge Code	64901271
Hospital Revenue Code	278
Min. Negotiated Rate	$127.45
Max. Negotiated Rate	$490.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$257.12
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	$233.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$268.81
Rate for Payer: Fidelis Medicare Advantage	$490.88
Rate for Payer: Group Health Inc Commercial	$233.75
Rate for Payer: Group Health Inc Medicare	$163.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$233.75
Rate for Payer: Hamaspik Choice Inc Medicare	$233.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$303.88

STENT URETERAL POLARIS 6X26FR

Facility OP

$380.63

Service Code	HCPCS C1877
Hospital Charge Code	64901289
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 URETERAL POLARIS 6X26FR

Facility IP

$380.63

Service Code	HCPCS C1877
Hospital Charge Code	64901289
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 URETERAL POLARIS 7FRX22CM

Facility OP

$358.75

Service Code	HCPCS C1877
Hospital Charge Code	64902329
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 URETERAL POLARIS 7FRX22CM

Facility IP

$358.75

Service Code	HCPCS C1877
Hospital Charge Code	64902329
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 URETERAL POLARIS 7FR X24CM

Facility OP

$358.75

Hospital Charge Code	64903951
Hospital Revenue Code	270
Min. Negotiated Rate	$125.56
Max. Negotiated Rate	$287.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$197.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$179.38
Rate for Payer: Aetna Government	$179.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$287.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$243.95
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

STENT URETERAL POLARIS 7FRX26CM

Facility OP

$358.75

Hospital Charge Code	64903953
Hospital Revenue Code	270
Min. Negotiated Rate	$125.56
Max. Negotiated Rate	$287.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$197.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$179.38
Rate for Payer: Aetna Government	$179.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$287.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$243.95
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

STENT URETERAL POLARIS 7FRX28CM

Facility OP

$358.75

Hospital Charge Code	64903955
Hospital Revenue Code	270
Min. Negotiated Rate	$125.56
Max. Negotiated Rate	$287.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$197.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$179.38
Rate for Payer: Aetna Government	$179.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$287.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$243.95
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

STENT URETERAL POLARIS 7FRX30CM

Facility OP

$487.50

Service Code	HCPCS C1877
Hospital Charge Code	64901205
Hospital Revenue Code	278
Min. Negotiated Rate	$127.45
Max. Negotiated Rate	$511.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$268.12
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	$243.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$280.31
Rate for Payer: Fidelis Medicare Advantage	$511.88
Rate for Payer: Group Health Inc Commercial	$243.75
Rate for Payer: Group Health Inc Medicare	$170.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$243.75
Rate for Payer: Hamaspik Choice Inc Medicare	$243.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$316.88

STENT URETERAL POLARIS 7FRX30CM

Facility IP

$487.50

Service Code	HCPCS C1877
Hospital Charge Code	64901205
Hospital Revenue Code	278
Min. Negotiated Rate	$243.75
Max. Negotiated Rate	$243.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$243.75
Rate for Payer: Hamaspik Choice Inc Medicare	$243.75

STENT URETERAL POLARIS 7FX20CM

Facility IP

$399.65

Service Code	HCPCS C1877
Hospital Charge Code	64902701
Hospital Revenue Code	278
Min. Negotiated Rate	$199.82
Max. Negotiated Rate	$199.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$199.82
Rate for Payer: Hamaspik Choice Inc Medicare	$199.82

STENT URETERAL POLARIS 7FX20CM

Facility OP

$399.65

Service Code	HCPCS C1877
Hospital Charge Code	64902701
Hospital Revenue Code	278
Min. Negotiated Rate	$127.45
Max. Negotiated Rate	$419.63
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$219.81
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	$199.82
Rate for Payer: Cigna LocalPlus Benefit Plan	$229.80
Rate for Payer: Fidelis Medicare Advantage	$419.63
Rate for Payer: Group Health Inc Commercial	$199.82
Rate for Payer: Group Health Inc Medicare	$139.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$199.82
Rate for Payer: Hamaspik Choice Inc Medicare	$199.82
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$259.77

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