St. Barnabas Hospital

All Charges

Charge

Type

Price

BOSTON SCI INGEVITY MRI 45CM 7740

Facility OP

$1,200.00

Service Code	HCPCS C1785
Hospital Charge Code	66573169
Hospital Revenue Code	275
Min. Negotiated Rate	$275.42
Max. Negotiated Rate	$1,260.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$660.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$275.42
Rate for Payer: Aetna Government	$275.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$690.00
Rate for Payer: Fidelis Medicare Advantage	$1,260.00
Rate for Payer: Group Health Inc Commercial	$600.00
Rate for Payer: Group Health Inc Medicare	$420.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$780.00

BOSTON SCI INGEVITY MRI 52CM 7741

Facility IP

$1,200.00

Service Code	HCPCS C1898
Hospital Charge Code	66573170
Hospital Revenue Code	278
Min. Negotiated Rate	$600.00
Max. Negotiated Rate	$600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$600.00

BOSTON SCI INGEVITY MRI 52CM 7741

Facility OP

$1,200.00

Service Code	HCPCS C1898
Hospital Charge Code	66573170
Hospital Revenue Code	278
Min. Negotiated Rate	$98.92
Max. Negotiated Rate	$1,260.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$660.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$98.92
Rate for Payer: Aetna Government	$98.92
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$690.00
Rate for Payer: Fidelis Medicare Advantage	$1,260.00
Rate for Payer: Group Health Inc Commercial	$600.00
Rate for Payer: Group Health Inc Medicare	$420.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$780.00

BOSTON SCI INGEVITY PPM LEAD 7740

Facility IP

$1,200.00

Service Code	HCPCS C1898
Hospital Charge Code	66573145
Hospital Revenue Code	278
Min. Negotiated Rate	$600.00
Max. Negotiated Rate	$600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$600.00

BOSTON SCI INGEVITY PPM LEAD 7740

Facility OP

$1,200.00

Service Code	HCPCS C1898
Hospital Charge Code	66573145
Hospital Revenue Code	278
Min. Negotiated Rate	$98.92
Max. Negotiated Rate	$1,260.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$660.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$98.92
Rate for Payer: Aetna Government	$98.92
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$690.00
Rate for Payer: Fidelis Medicare Advantage	$1,260.00
Rate for Payer: Group Health Inc Commercial	$600.00
Rate for Payer: Group Health Inc Medicare	$420.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$780.00

BOSTON SCI INOGEN EL ICD #D142

Facility OP

$42,500.00

Service Code	HCPCS C1721
Hospital Charge Code	66572922
Hospital Revenue Code	275
Min. Negotiated Rate	$5,000.00
Max. Negotiated Rate	$44,625.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$23,375.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5,000.00
Rate for Payer: Aetna Government	$5,000.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$21,250.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$24,437.50
Rate for Payer: Fidelis Medicare Advantage	$44,625.00
Rate for Payer: Group Health Inc Commercial	$21,250.00
Rate for Payer: Group Health Inc Medicare	$14,875.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$21,250.00
Rate for Payer: Hamaspik Choice Inc Medicare	$21,250.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$27,625.00

BOSTON SCI INTRO SHEATH 11FR

Facility OP

$100.00

Service Code	HCPCS C1894
Hospital Charge Code	66573278
Hospital Revenue Code	278
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$105.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$55.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.82
Rate for Payer: Aetna Government	$0.82
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$50.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$57.50
Rate for Payer: Fidelis Medicare Advantage	$105.00
Rate for Payer: Group Health Inc Commercial	$50.00
Rate for Payer: Group Health Inc Medicare	$35.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$50.00
Rate for Payer: Hamaspik Choice Inc Medicare	$50.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$65.00

BOSTON SCI INTRO SHEATH 11FR

Facility IP

$100.00

Service Code	HCPCS C1894
Hospital Charge Code	66573278
Hospital Revenue Code	278
Min. Negotiated Rate	$50.00
Max. Negotiated Rate	$50.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$50.00
Rate for Payer: Hamaspik Choice Inc Medicare	$50.00

BOSTON SCI RELIANCE ICD LEAD 0181

Facility OP

$10,000.00

Service Code	HCPCS C1777
Hospital Charge Code	66576697
Hospital Revenue Code	275
Min. Negotiated Rate	$988.18
Max. Negotiated Rate	$10,500.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,500.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$988.18
Rate for Payer: Aetna Government	$988.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5,000.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$5,750.00
Rate for Payer: Fidelis Medicare Advantage	$10,500.00
Rate for Payer: Group Health Inc Commercial	$5,000.00
Rate for Payer: Group Health Inc Medicare	$3,500.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,000.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,000.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$6,500.00

BOSTON SCI RELI SG SINGLE COIL 59

Facility OP

$11,200.00

Service Code	HCPCS C1777
Hospital Charge Code	66572895
Hospital Revenue Code	275
Min. Negotiated Rate	$988.18
Max. Negotiated Rate	$11,760.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6,160.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$988.18
Rate for Payer: Aetna Government	$988.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$6,440.00
Rate for Payer: Fidelis Medicare Advantage	$11,760.00
Rate for Payer: Group Health Inc Commercial	$5,600.00
Rate for Payer: Group Health Inc Medicare	$3,920.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7,280.00

BOSTON SCI WALLFLEX BIL STENT

Facility IP

$5,610.00

Service Code	HCPCS C1874
Hospital Charge Code	40009117
Hospital Revenue Code	278
Min. Negotiated Rate	$2,805.00
Max. Negotiated Rate	$2,805.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,805.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,805.00

BOSTON SCI WALLFLEX BIL STENT

Facility OP

$5,610.00

Service Code	HCPCS C1874
Hospital Charge Code	40009117
Hospital Revenue Code	278
Min. Negotiated Rate	$265.52
Max. Negotiated Rate	$5,890.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,085.50
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	$2,805.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,225.75
Rate for Payer: Fidelis Medicare Advantage	$5,890.50
Rate for Payer: Group Health Inc Commercial	$2,805.00
Rate for Payer: Group Health Inc Medicare	$1,963.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,805.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,805.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,646.50

BOSTON SCI WALLFLEX STENT 22X90MM

Facility IP

$5,170.92

Service Code	HCPCS C1876
Hospital Charge Code	40005500
Hospital Revenue Code	278
Min. Negotiated Rate	$2,585.46
Max. Negotiated Rate	$2,585.46
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,585.46
Rate for Payer: Hamaspik Choice Inc Medicare	$2,585.46

BOSTON SCI WALLFLEX STENT 22X90MM

Facility OP

$5,170.92

Service Code	HCPCS C1876
Hospital Charge Code	40005500
Hospital Revenue Code	278
Min. Negotiated Rate	$398.18
Max. Negotiated Rate	$5,429.47
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,844.01
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	$2,585.46
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,973.28
Rate for Payer: Fidelis Medicare Advantage	$5,429.47
Rate for Payer: Group Health Inc Commercial	$2,585.46
Rate for Payer: Group Health Inc Medicare	$1,809.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,585.46
Rate for Payer: Hamaspik Choice Inc Medicare	$2,585.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,361.10

BOTTOM 3/4 CONTAINER HEIGHT 120MM

Facility OP

$448.18

Hospital Charge Code	40209547
Hospital Revenue Code	270
Min. Negotiated Rate	$156.86
Max. Negotiated Rate	$358.54
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$246.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$224.09
Rate for Payer: Aetna Government	$224.09
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$358.54
Rate for Payer: Cigna LocalPlus Benefit Plan	$304.76
Rate for Payer: Group Health Inc Commercial	$224.09
Rate for Payer: Group Health Inc Medicare	$156.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$224.09
Rate for Payer: Hamaspik Choice Inc Medicare	$224.09

BOTULINUM TOXIN TYPE A 100 UNITS INJ

Facility IP

$19.00

Service Code	HCPCS J0585
Hospital Charge Code	41651593
Hospital Revenue Code	636
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$9.50
Rate for Payer: Cash Price	$6.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.50
Rate for Payer: Hamaspik Choice Inc Medicare	$9.50

BOTULINUM TOXIN TYPE A 100 UNITS INJ

Facility IP

$19.00

Service Code	HCPCS J0585
Hospital Charge Code	41641593
Hospital Revenue Code	636
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$9.50
Rate for Payer: Cash Price	$6.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.50
Rate for Payer: Hamaspik Choice Inc Medicare	$9.50

BOTULINUM TOXIN TYPE A 100 UNITS INJ

Facility OP

$19.00

Service Code	HCPCS J0585
Hospital Charge Code	41641593
Hospital Revenue Code	636
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$12.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$10.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.33
Rate for Payer: Aetna Government	$6.33
Rate for Payer: Cash Price	$6.33
Rate for Payer: Cash Price	$6.33
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$6.33
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.92
Rate for Payer: Elderplan Medicare Advantage	$6.33
Rate for Payer: EmblemHealth Commercial	$6.33
Rate for Payer: Fidelis CHP/HARP/Medicaid	$6.33
Rate for Payer: Fidelis Essential Plan Aliesa	$6.33
Rate for Payer: Fidelis Essential Plan QHP	$6.64
Rate for Payer: Fidelis Medicare Advantage	$6.33
Rate for Payer: Fidelis Qualified Health Plan	$6.64
Rate for Payer: Group Health Inc Commercial	$6.33
Rate for Payer: Group Health Inc Medicare	$6.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.50
Rate for Payer: Hamaspik Choice Inc Medicare	$9.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$6.39
Rate for Payer: Healthfirst Medicare Advantage	$5.38
Rate for Payer: Healthfirst QHP	$6.33
Rate for Payer: Senior Whole Health Medicare Advantage	$6.33
Rate for Payer: SOMOS CHP/HARP/Medicaid	$6.70
Rate for Payer: SOMOS Essential	$6.70
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12.35
Rate for Payer: Wellcare CHP/FHP/Medicaid	$5.06
Rate for Payer: Wellcare Medicare	$6.01

BOTULINUM TOXIN TYPE A 100 UNITS INJ

Facility OP

$19.00

Service Code	HCPCS J0585
Hospital Charge Code	41651593
Hospital Revenue Code	636
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$12.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$10.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.33
Rate for Payer: Aetna Government	$6.33
Rate for Payer: Cash Price	$6.33
Rate for Payer: Cash Price	$6.33
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$6.33
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.92
Rate for Payer: Elderplan Medicare Advantage	$6.33
Rate for Payer: EmblemHealth Commercial	$6.33
Rate for Payer: Fidelis CHP/HARP/Medicaid	$6.33
Rate for Payer: Fidelis Essential Plan Aliesa	$6.33
Rate for Payer: Fidelis Essential Plan QHP	$6.64
Rate for Payer: Fidelis Medicare Advantage	$6.33
Rate for Payer: Fidelis Qualified Health Plan	$6.64
Rate for Payer: Group Health Inc Commercial	$6.33
Rate for Payer: Group Health Inc Medicare	$6.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.50
Rate for Payer: Hamaspik Choice Inc Medicare	$9.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$6.39
Rate for Payer: Healthfirst Medicare Advantage	$5.38
Rate for Payer: Healthfirst QHP	$6.33
Rate for Payer: Senior Whole Health Medicare Advantage	$6.33
Rate for Payer: SOMOS CHP/HARP/Medicaid	$6.70
Rate for Payer: SOMOS Essential	$6.70
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12.35
Rate for Payer: Wellcare CHP/FHP/Medicaid	$5.06
Rate for Payer: Wellcare Medicare	$6.01

BOVINE CAROTID GRAFT 5MM X 39CM

Facility IP

$3,425.00

Service Code	HCPCS C1768
Hospital Charge Code	64906220
Hospital Revenue Code	278
Min. Negotiated Rate	$1,712.50
Max. Negotiated Rate	$1,712.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,712.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,712.50

BOVINE CAROTID GRAFT 5MM X 39CM

Facility OP

$3,425.00

Service Code	HCPCS C1768
Hospital Charge Code	64906220
Hospital Revenue Code	278
Min. Negotiated Rate	$322.77
Max. Negotiated Rate	$3,596.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,883.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,712.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,969.38
Rate for Payer: Fidelis Medicare Advantage	$3,596.25
Rate for Payer: Group Health Inc Commercial	$1,712.50
Rate for Payer: Group Health Inc Medicare	$1,198.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,712.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,712.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,226.25

BOVINE CAROTID GRAFT 5MM X 43CM

Facility IP

$1,419.00

Service Code	HCPCS C1768
Hospital Charge Code	40002337
Hospital Revenue Code	278
Min. Negotiated Rate	$709.50
Max. Negotiated Rate	$709.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$709.50
Rate for Payer: Hamaspik Choice Inc Medicare	$709.50

BOVINE CAROTID GRAFT 5MM X 43CM

Facility IP

$1,419.00

Service Code	HCPCS C1768
Hospital Charge Code	64906216
Hospital Revenue Code	278
Min. Negotiated Rate	$709.50
Max. Negotiated Rate	$709.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$709.50
Rate for Payer: Hamaspik Choice Inc Medicare	$709.50

BOVINE CAROTID GRAFT 5MM X 43CM

Facility OP

$1,419.00

Service Code	HCPCS C1768
Hospital Charge Code	64906216
Hospital Revenue Code	278
Min. Negotiated Rate	$322.77
Max. Negotiated Rate	$1,489.95
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$780.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$709.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$815.92
Rate for Payer: Fidelis Medicare Advantage	$1,489.95
Rate for Payer: Group Health Inc Commercial	$709.50
Rate for Payer: Group Health Inc Medicare	$496.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$709.50
Rate for Payer: Hamaspik Choice Inc Medicare	$709.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$922.35

BOVINE CAROTID GRAFT 5MM X 43CM

Facility OP

$1,419.00

Service Code	HCPCS C1768
Hospital Charge Code	40002337
Hospital Revenue Code	278
Min. Negotiated Rate	$322.77
Max. Negotiated Rate	$1,489.95
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$780.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$709.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$815.92
Rate for Payer: Fidelis Medicare Advantage	$1,489.95
Rate for Payer: Group Health Inc Commercial	$709.50
Rate for Payer: Group Health Inc Medicare	$496.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$709.50
Rate for Payer: Hamaspik Choice Inc Medicare	$709.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$922.35

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