St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

RELINE LOWER PARTIAL DENTURE (LAB

Facility

$312.50

Service Code	HCPCS D5761
Hospital Charge Code	42301155
Hospital Revenue Code	361
Min. Negotiated Rate	$109.38
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$171.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$121.26
Rate for Payer: Aetna Government	$121.26
Rate for Payer: Brighton Health Commercial	$234.38
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	$156.25
Rate for Payer: Group Health Inc Medicare	$109.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$156.25
Rate for Payer: Hamaspik Choice Inc Medicare	$156.25

RELINE MAS SCREW, 6.5X45MM 2C

Facility

$4,200.00

Service Code	HCPCS C1713
Hospital Charge Code	64905588
Hospital Revenue Code	278
Min. Negotiated Rate	$2,100.00
Max. Negotiated Rate	$2,100.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,100.00

RELINE MAS SCREW, 6.5X45MM 2C

Facility

$4,200.00

Service Code	HCPCS C1713
Hospital Charge Code	64905588
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$4,410.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,310.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$2,520.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,100.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,415.00
Rate for Payer: EmblemHealth Commercial	$2,100.00
Rate for Payer: Fidelis Medicare Advantage	$4,410.00
Rate for Payer: Group Health Inc Commercial	$2,100.00
Rate for Payer: Group Health Inc Medicare	$1,470.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,100.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,730.00

RELINE O CONN 5-6/5-6MM O-O

Facility

$4,220.00

Service Code	HCPCS C1713
Hospital Charge Code	64904818
Hospital Revenue Code	278
Min. Negotiated Rate	$2,110.00
Max. Negotiated Rate	$2,110.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,110.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,110.00

RELINE O CONN 5-6/5-6MM O-O

Facility

$4,220.00

Service Code	HCPCS C1713
Hospital Charge Code	64904818
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$4,431.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,321.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$2,532.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,110.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,426.50
Rate for Payer: EmblemHealth Commercial	$2,110.00
Rate for Payer: Fidelis Medicare Advantage	$4,431.00
Rate for Payer: Group Health Inc Commercial	$2,110.00
Rate for Payer: Group Health Inc Medicare	$1,477.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,110.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,110.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,743.00

RELINE O CONNECTR 20MM OFFSET

Facility

$2,837.50

Service Code	HCPCS C1713
Hospital Charge Code	64904814
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,979.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,560.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$1,702.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,418.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,631.56
Rate for Payer: EmblemHealth Commercial	$1,418.75
Rate for Payer: Fidelis Medicare Advantage	$2,979.38
Rate for Payer: Group Health Inc Commercial	$1,418.75
Rate for Payer: Group Health Inc Medicare	$993.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,418.75
Rate for Payer: Hamaspik Choice Inc Medicare	$1,418.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,844.38

RELINE O CONNECTR 20MM OFFSET

Facility

$2,837.50

Service Code	HCPCS C1713
Hospital Charge Code	64904814
Hospital Revenue Code	278
Min. Negotiated Rate	$1,418.75
Max. Negotiated Rate	$1,418.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,418.75
Rate for Payer: Hamaspik Choice Inc Medicare	$1,418.75

RELINE O TI ROD 5.5 300 ST

Facility

$2,207.50

Service Code	HCPCS C1713
Hospital Charge Code	64904816
Hospital Revenue Code	278
Min. Negotiated Rate	$1,103.75
Max. Negotiated Rate	$1,103.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,103.75
Rate for Payer: Hamaspik Choice Inc Medicare	$1,103.75

RELINE O TI ROD 5.5 300 ST

Facility

$2,207.50

Service Code	HCPCS C1713
Hospital Charge Code	64904816
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,317.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,214.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$1,324.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,103.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,269.31
Rate for Payer: EmblemHealth Commercial	$1,103.75
Rate for Payer: Fidelis Medicare Advantage	$2,317.88
Rate for Payer: Group Health Inc Commercial	$1,103.75
Rate for Payer: Group Health Inc Medicare	$772.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,103.75
Rate for Payer: Hamaspik Choice Inc Medicare	$1,103.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,434.88

RELINE O TI ROD 5.5X50MM

Facility

$1,077.50

Service Code	HCPCS C1713
Hospital Charge Code	64904621
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$1,131.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$592.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$646.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$538.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$619.56
Rate for Payer: EmblemHealth Commercial	$538.75
Rate for Payer: Fidelis Medicare Advantage	$1,131.38
Rate for Payer: Group Health Inc Commercial	$538.75
Rate for Payer: Group Health Inc Medicare	$377.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$538.75
Rate for Payer: Hamaspik Choice Inc Medicare	$538.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$700.38

RELINE O TI ROD 5.5X50MM

Facility

$1,077.50

Service Code	HCPCS C1713
Hospital Charge Code	64904621
Hospital Revenue Code	278
Min. Negotiated Rate	$538.75
Max. Negotiated Rate	$538.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$538.75
Rate for Payer: Hamaspik Choice Inc Medicare	$538.75

RELINE O TI ROD 5.5X65MM

Facility

$1,077.50

Service Code	HCPCS C1713
Hospital Charge Code	64904620
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$1,131.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$592.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$646.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$538.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$619.56
Rate for Payer: EmblemHealth Commercial	$538.75
Rate for Payer: Fidelis Medicare Advantage	$1,131.38
Rate for Payer: Group Health Inc Commercial	$538.75
Rate for Payer: Group Health Inc Medicare	$377.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$538.75
Rate for Payer: Hamaspik Choice Inc Medicare	$538.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$700.38

RELINE O TI ROD 5.5X65MM

Facility

$1,077.50

Service Code	HCPCS C1713
Hospital Charge Code	64904620
Hospital Revenue Code	278
Min. Negotiated Rate	$538.75
Max. Negotiated Rate	$538.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$538.75
Rate for Payer: Hamaspik Choice Inc Medicare	$538.75

RELINE UPPER PARTIAL DENTURE (CHA

Facility

$212.50

Service Code	HCPCS D5740
Hospital Charge Code	42301130
Hospital Revenue Code	361
Min. Negotiated Rate	$74.38
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$116.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$84.72
Rate for Payer: Aetna Government	$84.72
Rate for Payer: Brighton Health Commercial	$159.38
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	$106.25
Rate for Payer: Group Health Inc Medicare	$74.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$106.25
Rate for Payer: Hamaspik Choice Inc Medicare	$106.25

RELINE UPPER PARTIAL DENTURE (LAB

Facility

$312.50

Service Code	HCPCS D5760
Hospital Charge Code	42301150
Hospital Revenue Code	361
Min. Negotiated Rate	$109.38
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$171.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$121.26
Rate for Payer: Aetna Government	$121.26
Rate for Payer: Brighton Health Commercial	$234.38
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	$156.25
Rate for Payer: Group Health Inc Medicare	$109.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$156.25
Rate for Payer: Hamaspik Choice Inc Medicare	$156.25

RELISTOR 12MG/0.6ML INJ

Facility

$57.34

Hospital Charge Code	41658441
Hospital Revenue Code	250
Min. Negotiated Rate	$20.07
Max. Negotiated Rate	$45.87
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$31.54
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$28.67
Rate for Payer: Aetna Government	$28.67
Rate for Payer: Brighton Health Commercial	$43.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$45.87
Rate for Payer: Cigna LocalPlus Benefit Plan	$38.99
Rate for Payer: Group Health Inc Commercial	$28.67
Rate for Payer: Group Health Inc Medicare	$20.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$28.67
Rate for Payer: Hamaspik Choice Inc Medicare	$28.67
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$37.27

RELISTOR 12MG/0.6ML INJ

Facility

$57.34

Hospital Charge Code	41648441
Hospital Revenue Code	250
Min. Negotiated Rate	$20.07
Max. Negotiated Rate	$45.87
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$31.54
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$28.67
Rate for Payer: Aetna Government	$28.67
Rate for Payer: Brighton Health Commercial	$43.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$45.87
Rate for Payer: Cigna LocalPlus Benefit Plan	$38.99
Rate for Payer: Group Health Inc Commercial	$28.67
Rate for Payer: Group Health Inc Medicare	$20.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$28.67
Rate for Payer: Hamaspik Choice Inc Medicare	$28.67
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$37.27

RELISTOR 8MG/0.4ML INJ

Facility

$61.42

Hospital Charge Code	41658440
Hospital Revenue Code	250
Min. Negotiated Rate	$21.50
Max. Negotiated Rate	$49.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$33.78
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$30.71
Rate for Payer: Aetna Government	$30.71
Rate for Payer: Brighton Health Commercial	$46.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$49.14
Rate for Payer: Cigna LocalPlus Benefit Plan	$41.77
Rate for Payer: Group Health Inc Commercial	$30.71
Rate for Payer: Group Health Inc Medicare	$21.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$30.71
Rate for Payer: Hamaspik Choice Inc Medicare	$30.71
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$39.92

RELISTOR 8MG/0.4ML INJ

Facility

$61.42

Hospital Charge Code	41648440
Hospital Revenue Code	250
Min. Negotiated Rate	$21.50
Max. Negotiated Rate	$49.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$33.78
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$30.71
Rate for Payer: Aetna Government	$30.71
Rate for Payer: Brighton Health Commercial	$46.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$49.14
Rate for Payer: Cigna LocalPlus Benefit Plan	$41.77
Rate for Payer: Group Health Inc Commercial	$30.71
Rate for Payer: Group Health Inc Medicare	$21.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$30.71
Rate for Payer: Hamaspik Choice Inc Medicare	$30.71
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$39.92

RELOAD BLUE

Facility

$410.92

Hospital Charge Code	64905163
Hospital Revenue Code	270
Min. Negotiated Rate	$143.82
Max. Negotiated Rate	$328.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$226.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$205.46
Rate for Payer: Aetna Government	$205.46
Rate for Payer: Brighton Health Commercial	$308.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$328.74
Rate for Payer: Cigna LocalPlus Benefit Plan	$279.43
Rate for Payer: Group Health Inc Commercial	$205.46
Rate for Payer: Group Health Inc Medicare	$143.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$205.46
Rate for Payer: Hamaspik Choice Inc Medicare	$205.46

RELOAD ENDO GIA 45 DUET4535A

Facility

$801.12

Hospital Charge Code	40205109
Hospital Revenue Code	270
Min. Negotiated Rate	$280.39
Max. Negotiated Rate	$640.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$440.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$400.56
Rate for Payer: Aetna Government	$400.56
Rate for Payer: Brighton Health Commercial	$600.84
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$640.90
Rate for Payer: Cigna LocalPlus Benefit Plan	$544.76
Rate for Payer: Group Health Inc Commercial	$400.56
Rate for Payer: Group Health Inc Medicare	$280.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$400.56
Rate for Payer: Hamaspik Choice Inc Medicare	$400.56

RELOAD ENDO GIA60

Facility

$872.00

Hospital Charge Code	40206048
Hospital Revenue Code	270
Min. Negotiated Rate	$305.20
Max. Negotiated Rate	$697.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$479.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$436.00
Rate for Payer: Aetna Government	$436.00
Rate for Payer: Brighton Health Commercial	$654.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$697.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$592.96
Rate for Payer: Group Health Inc Commercial	$436.00
Rate for Payer: Group Health Inc Medicare	$305.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$436.00
Rate for Payer: Hamaspik Choice Inc Medicare	$436.00

RELOAD ENDSTCH SRGIDAC 2-0 7GRN

Facility

$322.35

Hospital Charge Code	64904622
Hospital Revenue Code	270
Min. Negotiated Rate	$112.82
Max. Negotiated Rate	$257.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$177.29
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$161.18
Rate for Payer: Aetna Government	$161.18
Rate for Payer: Brighton Health Commercial	$241.76
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$257.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$219.20
Rate for Payer: Group Health Inc Commercial	$161.18
Rate for Payer: Group Health Inc Medicare	$112.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$161.18
Rate for Payer: Hamaspik Choice Inc Medicare	$161.18

RELOAD,ETHICON,ECHELON,VASCULAR

Facility

$268.91

Hospital Charge Code	64902934
Hospital Revenue Code	270
Min. Negotiated Rate	$94.12
Max. Negotiated Rate	$215.13
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$147.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.46
Rate for Payer: Aetna Government	$134.46
Rate for Payer: Brighton Health Commercial	$201.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$215.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$182.86
Rate for Payer: Group Health Inc Commercial	$134.46
Rate for Payer: Group Health Inc Medicare	$94.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$134.46
Rate for Payer: Hamaspik Choice Inc Medicare	$134.46

RELOAD GREEN

Facility

$360.46

Hospital Charge Code	64905165
Hospital Revenue Code	270
Min. Negotiated Rate	$126.16
Max. Negotiated Rate	$288.37
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$198.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$180.23
Rate for Payer: Aetna Government	$180.23
Rate for Payer: Brighton Health Commercial	$270.34
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$288.37
Rate for Payer: Cigna LocalPlus Benefit Plan	$245.11
Rate for Payer: Group Health Inc Commercial	$180.23
Rate for Payer: Group Health Inc Medicare	$126.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$180.23
Rate for Payer: Hamaspik Choice Inc Medicare	$180.23

Know your out-of-pocket cost for care.

All Charges