St. Barnabas Hospital

All Charges

Charge

Type

Price

BIPIV 0.25%/NS 250ML

Facility IP

$12.00

Service Code	HCPCS J3490
Hospital Charge Code	41655931
Hospital Revenue Code	636
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$6.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.00
Rate for Payer: Hamaspik Choice Inc Medicare	$6.00

BIPIV 0.25%/NS 250ML

Facility OP

$12.00

Service Code	HCPCS J3490
Hospital Charge Code	41645931
Hospital Revenue Code	636
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$7.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.00
Rate for Payer: Aetna Government	$6.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.90
Rate for Payer: Group Health Inc Commercial	$6.00
Rate for Payer: Group Health Inc Medicare	$4.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.00
Rate for Payer: Hamaspik Choice Inc Medicare	$6.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7.80

BIPIV 0.25%/NS 250ML

Facility IP

$12.00

Service Code	HCPCS J3490
Hospital Charge Code	41645931
Hospital Revenue Code	636
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$6.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.00
Rate for Payer: Hamaspik Choice Inc Medicare	$6.00

BIPIV 0.25%/NS 250ML

Facility OP

$12.00

Service Code	HCPCS J3490
Hospital Charge Code	41655931
Hospital Revenue Code	636
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$7.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.00
Rate for Payer: Aetna Government	$6.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.90
Rate for Payer: Group Health Inc Commercial	$6.00
Rate for Payer: Group Health Inc Medicare	$4.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.00
Rate for Payer: Hamaspik Choice Inc Medicare	$6.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7.80

BIPOLAR CABLE

Facility OP

$695.13

Hospital Charge Code	64905815
Hospital Revenue Code	270
Min. Negotiated Rate	$243.30
Max. Negotiated Rate	$556.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$382.32
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$347.56
Rate for Payer: Aetna Government	$347.56
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$556.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$472.69
Rate for Payer: Group Health Inc Commercial	$347.56
Rate for Payer: Group Health Inc Medicare	$243.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$347.56
Rate for Payer: Hamaspik Choice Inc Medicare	$347.56

BIPOLAR COMPONENT/HEAD/RING

Facility IP

$2,758.60

Service Code	HCPCS C1776
Hospital Charge Code	40203094
Hospital Revenue Code	278
Min. Negotiated Rate	$1,379.30
Max. Negotiated Rate	$1,379.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,379.30
Rate for Payer: Hamaspik Choice Inc Medicare	$1,379.30

BIPOLAR COMPONENT/HEAD/RING

Facility OP

$2,758.60

Service Code	HCPCS C1776
Hospital Charge Code	40203094
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$2,896.53
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,517.23
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,379.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,586.20
Rate for Payer: Fidelis Medicare Advantage	$2,896.53
Rate for Payer: Group Health Inc Commercial	$1,379.30
Rate for Payer: Group Health Inc Medicare	$965.51
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,379.30
Rate for Payer: Hamaspik Choice Inc Medicare	$1,379.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,793.09

BIPOLAR CUP

Facility OP

$2,194.00

Hospital Charge Code	40202254
Hospital Revenue Code	270
Min. Negotiated Rate	$767.90
Max. Negotiated Rate	$1,755.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,206.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,097.00
Rate for Payer: Aetna Government	$1,097.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,755.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,491.92
Rate for Payer: Group Health Inc Commercial	$1,097.00
Rate for Payer: Group Health Inc Medicare	$767.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,097.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,097.00

BIPOLAR FRCPS DSP 8 .5MM STR

Facility OP

$2,125.00

Hospital Charge Code	64906298
Hospital Revenue Code	270
Min. Negotiated Rate	$743.75
Max. Negotiated Rate	$1,700.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,168.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,062.50
Rate for Payer: Aetna Government	$1,062.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,700.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,445.00
Rate for Payer: Group Health Inc Commercial	$1,062.50
Rate for Payer: Group Health Inc Medicare	$743.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,062.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,062.50

BI POLAR HEAD 28X51

Facility OP

$2,085.63

Service Code	HCPCS C1713
Hospital Charge Code	64903639
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,189.91
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,147.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,042.82
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,199.24
Rate for Payer: Fidelis Medicare Advantage	$2,189.91
Rate for Payer: Group Health Inc Commercial	$1,042.82
Rate for Payer: Group Health Inc Medicare	$729.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,042.82
Rate for Payer: Hamaspik Choice Inc Medicare	$1,042.82
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,355.66

BI POLAR HEAD 28X51

Facility IP

$2,085.63

Service Code	HCPCS C1713
Hospital Charge Code	64903639
Hospital Revenue Code	278
Min. Negotiated Rate	$1,042.82
Max. Negotiated Rate	$1,042.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,042.82
Rate for Payer: Hamaspik Choice Inc Medicare	$1,042.82

BIPOLAR HIP PROSTHESIS

Facility OP

$3,944.00

Service Code	HCPCS 27125
Hospital Charge Code	40021425
Hospital Revenue Code	360
Min. Negotiated Rate	$1,171.35
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,169.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,171.35
Rate for Payer: Aetna Government	$1,171.35
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: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1,283.72
Rate for Payer: Group Health Inc Commercial	$1,972.00
Rate for Payer: Group Health Inc Medicare	$1,380.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,972.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,972.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1,426.35

BIPOLAR LOOP ELECTRODE

Facility OP

$250.00

Hospital Charge Code	64905753
Hospital Revenue Code	270
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$200.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$137.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$125.00
Rate for Payer: Aetna Government	$125.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$200.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$170.00
Rate for Payer: Group Health Inc Commercial	$125.00
Rate for Payer: Group Health Inc Medicare	$87.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$125.00
Rate for Payer: Hamaspik Choice Inc Medicare	$125.00

BISACODYL 10 MG RECTAL

Facility OP

$1.00

Hospital Charge Code	41650414
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

BISACODYL 10 MG RECTAL

Facility OP

$1.00

Hospital Charge Code	41640414
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

BISACODYL 5 MG TAB

Facility OP

$0.05

Hospital Charge Code	41653103
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.03
Rate for Payer: Aetna Government	$0.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.03
Rate for Payer: Group Health Inc Commercial	$0.03
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03
Rate for Payer: Hamaspik Choice Inc Medicare	$0.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.03

BISACODYL 5 MG TAB

Facility OP

$0.05

Hospital Charge Code	41643103
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.03
Rate for Payer: Aetna Government	$0.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.03
Rate for Payer: Group Health Inc Commercial	$0.03
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03
Rate for Payer: Hamaspik Choice Inc Medicare	$0.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.03

BISMUTH SUBSALICYLATE 262 MG/15 ML SUSP

Facility OP

$1.00

Hospital Charge Code	41640691
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

BISMUTH SUBSALICYLATE 262 MG/15 ML SUSP

Facility OP

$1.00

Hospital Charge Code	41650691
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

BISMUTH SUBSALICYLATE 262 MG CHEW TAB

Facility OP

$1.00

Hospital Charge Code	41654981
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

BISMUTH SUBSALICYLATE 262 MG CHEW TAB

Facility OP

$1.00

Hospital Charge Code	41644981
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

BISMUTH SUBSALICYLATE 524MG/30 UD

Facility OP

$4.80

Hospital Charge Code	41647919
Hospital Revenue Code	250
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$3.84
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.40
Rate for Payer: Aetna Government	$2.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.26
Rate for Payer: Group Health Inc Commercial	$2.40
Rate for Payer: Group Health Inc Medicare	$1.68
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.40
Rate for Payer: Hamaspik Choice Inc Medicare	$2.40
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.12

BISMUUTH SUBSALICYLATE 524MG/30 U

Facility OP

$4.80

Hospital Charge Code	41657919
Hospital Revenue Code	250
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$3.84
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.40
Rate for Payer: Aetna Government	$2.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.26
Rate for Payer: Group Health Inc Commercial	$2.40
Rate for Payer: Group Health Inc Medicare	$1.68
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.40
Rate for Payer: Hamaspik Choice Inc Medicare	$2.40
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.12

BIT 20 HOLD STRIGHT

Facility OP

$1,054.68

Hospital Charge Code	64906029
Hospital Revenue Code	270
Min. Negotiated Rate	$369.14
Max. Negotiated Rate	$843.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$580.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$527.34
Rate for Payer: Aetna Government	$527.34
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$843.74
Rate for Payer: Cigna LocalPlus Benefit Plan	$717.18
Rate for Payer: Group Health Inc Commercial	$527.34
Rate for Payer: Group Health Inc Medicare	$369.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$527.34
Rate for Payer: Hamaspik Choice Inc Medicare	$527.34

BIT DRILL

Facility OP

$455.00

Service Code	HCPCS C1713
Hospital Charge Code	64907232
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$477.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$250.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$227.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$261.62
Rate for Payer: Fidelis Medicare Advantage	$477.75
Rate for Payer: Group Health Inc Commercial	$227.50
Rate for Payer: Group Health Inc Medicare	$159.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$227.50
Rate for Payer: Hamaspik Choice Inc Medicare	$227.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$295.75

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