St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

STENT URETERAL 7FRX24CM

Facility

$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 7FRX24CM

Facility

$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: Brighton Health Commercial	$210.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$175.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$201.25
Rate for Payer: EmblemHealth Commercial	$175.00
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 7FRX26CM

Facility

$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

$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: Brighton Health Commercial	$234.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$195.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$224.25
Rate for Payer: EmblemHealth Commercial	$195.00
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

$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

$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: Brighton Health Commercial	$154.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$129.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$148.35
Rate for Payer: EmblemHealth Commercial	$129.00
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

$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: Brighton Health Commercial	$269.06
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

$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: Brighton Health Commercial	$280.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$233.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$268.81
Rate for Payer: EmblemHealth Commercial	$233.75
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 6FRX20CM

Facility

$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 6X26FR

Facility

$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 6X26FR

Facility

$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: Brighton Health Commercial	$228.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$190.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$218.86
Rate for Payer: EmblemHealth Commercial	$190.32
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 7FRX22CM

Facility

$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 7FRX22CM

Facility

$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: Brighton Health Commercial	$215.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$179.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$206.28
Rate for Payer: EmblemHealth Commercial	$179.38
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 7FR X24CM

Facility

$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: Brighton Health Commercial	$269.06
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

$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: Brighton Health Commercial	$269.06
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

$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: Brighton Health Commercial	$269.06
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

$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 7FRX30CM

Facility

$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: Brighton Health Commercial	$292.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$243.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$280.31
Rate for Payer: EmblemHealth Commercial	$243.75
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 7FX20CM

Facility

$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: Brighton Health Commercial	$239.79
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$199.82
Rate for Payer: Cigna LocalPlus Benefit Plan	$229.80
Rate for Payer: EmblemHealth Commercial	$199.82
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

STENT URETERAL POLARIS 7FX20CM

Facility

$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 VIABHAN EXPAND 8X 39MX135CM

Facility

$3,255.00

Service Code	HCPCS C1874
Hospital Charge Code	64906501
Hospital Revenue Code	278
Min. Negotiated Rate	$1,627.50
Max. Negotiated Rate	$1,627.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,627.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,627.50

STENT VIABHAN EXPAND 8X 39MX135CM

Facility

$3,255.00

Service Code	HCPCS C1874
Hospital Charge Code	64906501
Hospital Revenue Code	278
Min. Negotiated Rate	$265.52
Max. Negotiated Rate	$3,417.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,790.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$265.52
Rate for Payer: Aetna Government	$265.52
Rate for Payer: Brighton Health Commercial	$1,953.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,627.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,871.62
Rate for Payer: EmblemHealth Commercial	$1,627.50
Rate for Payer: Fidelis Medicare Advantage	$3,417.75
Rate for Payer: Group Health Inc Commercial	$1,627.50
Rate for Payer: Group Health Inc Medicare	$1,139.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,627.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,627.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,115.75

STENT VIABHN W/HPRN 5MMX5CM

Facility

$7,046.00

Service Code	HCPCS C1874
Hospital Charge Code	64906540
Hospital Revenue Code	278
Min. Negotiated Rate	$3,523.00
Max. Negotiated Rate	$3,523.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,523.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,523.00

STENT VIABHN W/HPRN 5MMX5CM

Facility

$7,046.00

Service Code	HCPCS C1874
Hospital Charge Code	64906540
Hospital Revenue Code	278
Min. Negotiated Rate	$265.52
Max. Negotiated Rate	$7,398.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,875.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$265.52
Rate for Payer: Aetna Government	$265.52
Rate for Payer: Brighton Health Commercial	$4,227.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,523.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,051.45
Rate for Payer: EmblemHealth Commercial	$3,523.00
Rate for Payer: Fidelis Medicare Advantage	$7,398.30
Rate for Payer: Group Health Inc Commercial	$3,523.00
Rate for Payer: Group Health Inc Medicare	$2,466.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,523.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,523.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,579.90

STENT VIABHN W/HPRN 6MMX5CM

Facility

$7,046.00

Service Code	HCPCS C1874
Hospital Charge Code	64906541
Hospital Revenue Code	278
Min. Negotiated Rate	$3,523.00
Max. Negotiated Rate	$3,523.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,523.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,523.00

Know your out-of-pocket cost for care.

All Charges