St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

SELENIUM SULFIDE 2.5 % EX LOTN [37630]

Facility

$0.17

Service Code	NDC 45802004064
Hospital Charge Code	45802004064
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.13
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.09
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.08
Rate for Payer: Aetna Government	$0.08
Rate for Payer: Brighton Health Commercial	$0.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.11
Rate for Payer: Group Health Inc Commercial	$0.08
Rate for Payer: Group Health Inc Medicare	$0.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.08
Rate for Payer: Hamaspik Choice Inc Medicare	$0.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.11

SELENIUM SULFIDE 2.5% SHAMPOO

Facility

$14.00

Hospital Charge Code	41640220
Hospital Revenue Code	250
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$11.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.00
Rate for Payer: Aetna Government	$7.00
Rate for Payer: Brighton Health Commercial	$10.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.52
Rate for Payer: Group Health Inc Commercial	$7.00
Rate for Payer: Group Health Inc Medicare	$4.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.10

SELENIUM SULFIDE 2.5% SHAMPOO

Facility

$14.00

Hospital Charge Code	41650220
Hospital Revenue Code	250
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$11.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.00
Rate for Payer: Aetna Government	$7.00
Rate for Payer: Brighton Health Commercial	$10.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.52
Rate for Payer: Group Health Inc Commercial	$7.00
Rate for Payer: Group Health Inc Medicare	$4.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.10

SELF ADHERENT BANDAGE >3 IN

Facility

$1.62

Service Code	HCPCS A6454
Hospital Charge Code	41809573
Hospital Revenue Code	270
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$1.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.89
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.47
Rate for Payer: Aetna Government	$0.47
Rate for Payer: Brighton Health Commercial	$1.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.10
Rate for Payer: Group Health Inc Commercial	$0.81
Rate for Payer: Group Health Inc Medicare	$0.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.81
Rate for Payer: Hamaspik Choice Inc Medicare	$0.81

SELF ADHERENT BANDAGE<3IN

Facility

$1.28

Service Code	HCPCS A6453
Hospital Charge Code	41809572
Hospital Revenue Code	270
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$1.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.38
Rate for Payer: Aetna Government	$0.38
Rate for Payer: Brighton Health Commercial	$0.96
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.87
Rate for Payer: Group Health Inc Commercial	$0.64
Rate for Payer: Group Health Inc Medicare	$0.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.64
Rate for Payer: Hamaspik Choice Inc Medicare	$0.64

SELF ADHERENT BANDAGE < 5 IN

Facility

$2.92

Service Code	HCPCS A6455
Hospital Charge Code	41809574
Hospital Revenue Code	270
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$2.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.85
Rate for Payer: Aetna Government	$0.85
Rate for Payer: Brighton Health Commercial	$2.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.99
Rate for Payer: Group Health Inc Commercial	$1.46
Rate for Payer: Group Health Inc Medicare	$1.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.46
Rate for Payer: Hamaspik Choice Inc Medicare	$1.46

SELF CENT HIP 53X28 BLU

Facility

$3,452.50

Service Code	HCPCS C1776
Hospital Charge Code	64903610
Hospital Revenue Code	278
Min. Negotiated Rate	$1,726.25
Max. Negotiated Rate	$1,726.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,726.25
Rate for Payer: Hamaspik Choice Inc Medicare	$1,726.25

SELF CENT HIP 53X28 BLU

Facility

$3,452.50

Service Code	HCPCS C1776
Hospital Charge Code	64903610
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$3,625.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,898.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,071.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,726.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,985.19
Rate for Payer: EmblemHealth Commercial	$1,726.25
Rate for Payer: Fidelis Medicare Advantage	$3,625.12
Rate for Payer: Group Health Inc Commercial	$1,726.25
Rate for Payer: Group Health Inc Medicare	$1,208.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,726.25
Rate for Payer: Hamaspik Choice Inc Medicare	$1,726.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,244.12

SELF CENT HIP 54X28 BLU

Facility

$3,260.00

Service Code	HCPCS C1776
Hospital Charge Code	40005145
Hospital Revenue Code	278
Min. Negotiated Rate	$1,630.00
Max. Negotiated Rate	$1,630.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,630.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,630.00

SELF CENT HIP 54X28 BLU

Facility

$4,075.00

Service Code	HCPCS C1776
Hospital Charge Code	64905204
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$4,278.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,241.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,445.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,037.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,343.12
Rate for Payer: EmblemHealth Commercial	$2,037.50
Rate for Payer: Fidelis Medicare Advantage	$4,278.75
Rate for Payer: Group Health Inc Commercial	$2,037.50
Rate for Payer: Group Health Inc Medicare	$1,426.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,037.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2,037.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,648.75

SELF CENT HIP 54X28 BLU

Facility

$3,260.00

Service Code	HCPCS C1776
Hospital Charge Code	40005145
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$3,423.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,793.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$1,956.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,630.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,874.50
Rate for Payer: EmblemHealth Commercial	$1,630.00
Rate for Payer: Fidelis Medicare Advantage	$3,423.00
Rate for Payer: Group Health Inc Commercial	$1,630.00
Rate for Payer: Group Health Inc Medicare	$1,141.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,630.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,630.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,119.00

SELF CENT HIP 54X28 BLU

Facility

$4,075.00

Service Code	HCPCS C1776
Hospital Charge Code	64905204
Hospital Revenue Code	278
Min. Negotiated Rate	$2,037.50
Max. Negotiated Rate	$2,037.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,037.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2,037.50

SELF DRILLING MID FACE W

Facility

$247.50

Service Code	HCPCS C1713
Hospital Charge Code	64904716
Hospital Revenue Code	278
Min. Negotiated Rate	$86.62
Max. Negotiated Rate	$259.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$136.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$148.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$123.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$142.31
Rate for Payer: EmblemHealth Commercial	$123.75
Rate for Payer: Fidelis Medicare Advantage	$259.88
Rate for Payer: Group Health Inc Commercial	$123.75
Rate for Payer: Group Health Inc Medicare	$86.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$123.75
Rate for Payer: Hamaspik Choice Inc Medicare	$123.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$160.88

SELF DRILLING MID FACE W

Facility

$247.50

Service Code	HCPCS C1713
Hospital Charge Code	64904716
Hospital Revenue Code	278
Min. Negotiated Rate	$123.75
Max. Negotiated Rate	$123.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$123.75
Rate for Payer: Hamaspik Choice Inc Medicare	$123.75

SELF DRILL MID-FACE

Facility

$247.50

Service Code	HCPCS C1713
Hospital Charge Code	64904634
Hospital Revenue Code	278
Min. Negotiated Rate	$123.75
Max. Negotiated Rate	$123.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$123.75
Rate for Payer: Hamaspik Choice Inc Medicare	$123.75

SELF DRILL MID-FACE

Facility

$247.50

Service Code	HCPCS C1713
Hospital Charge Code	64904634
Hospital Revenue Code	278
Min. Negotiated Rate	$86.62
Max. Negotiated Rate	$259.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$136.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$148.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$123.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$142.31
Rate for Payer: EmblemHealth Commercial	$123.75
Rate for Payer: Fidelis Medicare Advantage	$259.88
Rate for Payer: Group Health Inc Commercial	$123.75
Rate for Payer: Group Health Inc Medicare	$86.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$123.75
Rate for Payer: Hamaspik Choice Inc Medicare	$123.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$160.88

SELF-HELP/PEER SVC PER 15 MIN

Facility

$27.98

Service Code	HCPCS H0038
Hospital Charge Code	30400246
Hospital Revenue Code	900
Min. Negotiated Rate	$7.84
Max. Negotiated Rate	$3,349.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$15.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.84
Rate for Payer: Aetna Government	$7.84
Rate for Payer: Affinity Essential Plan 1&2	$75.35
Rate for Payer: Affinity Essential Plan 3&4	$75.35
Rate for Payer: Affinity Medicaid/CHP/HARP	$33.49
Rate for Payer: Amida Care Medicaid	$33.49
Rate for Payer: Brighton Health Commercial	$20.98
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$22.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$19.03
Rate for Payer: Fidelis CHP/HARP/Medicaid	$3,349.00
Rate for Payer: Fidelis Essential Plan Aliesa	$33.49
Rate for Payer: Fidelis Essential Plan QHP	$33.49
Rate for Payer: Fidelis Qualified Health Plan	$35.16
Rate for Payer: Group Health Inc Commercial	$13.99
Rate for Payer: Group Health Inc Medicare	$9.79
Rate for Payer: Hamaspik Choice Inc Medicaid	$33.49
Rate for Payer: Hamaspik Choice Inc Medicare	$13.99
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$33.49
Rate for Payer: Healthfirst Essential Plan	$75.35
Rate for Payer: Healthfirst QHP	$33.49
Rate for Payer: SOMOS CHP/HARP/Medicaid	$33.49
Rate for Payer: SOMOS Essential	$75.35
Rate for Payer: United Healthcare Commercial	$13.99
Rate for Payer: United Healthcare Essential Plan 1&2	$75.35
Rate for Payer: United Healthcare Essential Plan 3&4	$36.84
Rate for Payer: United Healthcare Medicaid	$33.49
Rate for Payer: Wellcare CHP/FHP/Medicaid	$33.49

SEMI CIRCULAR CURVED ROD 8 X 174

Facility

$180.50

Service Code	HCPCS C1713
Hospital Charge Code	40200287
Hospital Revenue Code	278
Min. Negotiated Rate	$90.25
Max. Negotiated Rate	$90.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$90.25
Rate for Payer: Hamaspik Choice Inc Medicare	$90.25

SEMI CIRCULAR CURVED ROD 8 X 174

Facility

$180.50

Service Code	HCPCS C1713
Hospital Charge Code	40200287
Hospital Revenue Code	278
Min. Negotiated Rate	$63.18
Max. Negotiated Rate	$189.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$99.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$108.30
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$90.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$103.79
Rate for Payer: EmblemHealth Commercial	$90.25
Rate for Payer: Fidelis Medicare Advantage	$189.52
Rate for Payer: Group Health Inc Commercial	$90.25
Rate for Payer: Group Health Inc Medicare	$63.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$90.25
Rate for Payer: Hamaspik Choice Inc Medicare	$90.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$117.32

SEMI CIRCULAR CURVED ROD8X174

Facility

$536.20

Service Code	HCPCS C1713
Hospital Charge Code	40209954
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$563.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$294.91
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$321.72
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$268.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$308.32
Rate for Payer: EmblemHealth Commercial	$268.10
Rate for Payer: Fidelis Medicare Advantage	$563.01
Rate for Payer: Group Health Inc Commercial	$268.10
Rate for Payer: Group Health Inc Medicare	$187.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$268.10
Rate for Payer: Hamaspik Choice Inc Medicare	$268.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$348.53

SEMI CIRCULAR CURVED ROD8X174

Facility

$536.20

Service Code	HCPCS C1713
Hospital Charge Code	40209954
Hospital Revenue Code	278
Min. Negotiated Rate	$268.10
Max. Negotiated Rate	$268.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$268.10
Rate for Payer: Hamaspik Choice Inc Medicare	$268.10

SEMI-TENDINOUS TENDON (FST)

Facility

$4,850.00

Service Code	HCPCS C1762
Hospital Charge Code	40202934
Hospital Revenue Code	278
Min. Negotiated Rate	$2,425.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,425.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,425.00

SEMI-TENDINOUS TENDON (FST)

Facility

$4,850.00

Service Code	HCPCS C1762
Hospital Charge Code	64903673
Hospital Revenue Code	278
Min. Negotiated Rate	$2,425.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,425.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,425.00

SEMI-TENDINOUS TENDON (FST)

Facility

$4,850.00

Service Code	HCPCS C1762
Hospital Charge Code	64903673
Hospital Revenue Code	278
Min. Negotiated Rate	$1,697.50
Max. Negotiated Rate	$5,092.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,667.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,879.82
Rate for Payer: Aetna Government	$1,879.82
Rate for Payer: Brighton Health Commercial	$2,910.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,425.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,788.75
Rate for Payer: EmblemHealth Commercial	$2,425.00
Rate for Payer: Fidelis Medicare Advantage	$5,092.50
Rate for Payer: Group Health Inc Commercial	$2,425.00
Rate for Payer: Group Health Inc Medicare	$1,697.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,425.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,425.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,152.50

SEMI-TENDINOUS TENDON (FST)

Facility

$4,850.00

Service Code	HCPCS C1762
Hospital Charge Code	40202934
Hospital Revenue Code	278
Min. Negotiated Rate	$1,697.50
Max. Negotiated Rate	$5,092.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,667.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,879.82
Rate for Payer: Aetna Government	$1,879.82
Rate for Payer: Brighton Health Commercial	$2,910.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,425.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,788.75
Rate for Payer: EmblemHealth Commercial	$2,425.00
Rate for Payer: Fidelis Medicare Advantage	$5,092.50
Rate for Payer: Group Health Inc Commercial	$2,425.00
Rate for Payer: Group Health Inc Medicare	$1,697.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,425.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,425.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,152.50

Know your out-of-pocket cost for care.

All Charges