St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

5HLE L PLTE2MM ADVMT100D RGHT STD

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40201095
Hospital Revenue Code	278
Min. Negotiated Rate	$157.00
Max. Negotiated Rate	$157.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$157.00
Rate for Payer: Hamaspik Choice Inc Medicare	$157.00

5HLE L PLTE2MM ADVMT100D RGHT STD

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40201095
Hospital Revenue Code	278
Min. Negotiated Rate	$109.90
Max. Negotiated Rate	$329.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$172.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$188.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$157.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$180.55
Rate for Payer: EmblemHealth Commercial	$157.00
Rate for Payer: Fidelis Medicare Advantage	$329.70
Rate for Payer: Group Health Inc Commercial	$157.00
Rate for Payer: Group Health Inc Medicare	$109.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$157.00
Rate for Payer: Hamaspik Choice Inc Medicare	$157.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$204.10

5HLE L PLTE5MM ADVMT100D LFT STD

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40201098
Hospital Revenue Code	278
Min. Negotiated Rate	$109.90
Max. Negotiated Rate	$329.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$172.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$188.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$157.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$180.55
Rate for Payer: EmblemHealth Commercial	$157.00
Rate for Payer: Fidelis Medicare Advantage	$329.70
Rate for Payer: Group Health Inc Commercial	$157.00
Rate for Payer: Group Health Inc Medicare	$109.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$157.00
Rate for Payer: Hamaspik Choice Inc Medicare	$157.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$204.10

5HLE L PLTE5MM ADVMT100D LFT STD

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40201098
Hospital Revenue Code	278
Min. Negotiated Rate	$157.00
Max. Negotiated Rate	$157.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$157.00
Rate for Payer: Hamaspik Choice Inc Medicare	$157.00

5HLE L PLTE5MM ADVMT100D RGHT GSP

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40201099
Hospital Revenue Code	278
Min. Negotiated Rate	$157.00
Max. Negotiated Rate	$157.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$157.00
Rate for Payer: Hamaspik Choice Inc Medicare	$157.00

5HLE L PLTE5MM ADVMT100D RGHT GSP

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40201099
Hospital Revenue Code	278
Min. Negotiated Rate	$109.90
Max. Negotiated Rate	$329.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$172.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$188.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$157.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$180.55
Rate for Payer: EmblemHealth Commercial	$157.00
Rate for Payer: Fidelis Medicare Advantage	$329.70
Rate for Payer: Group Health Inc Commercial	$157.00
Rate for Payer: Group Health Inc Medicare	$109.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$157.00
Rate for Payer: Hamaspik Choice Inc Medicare	$157.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$204.10

5HLE L PLTE5MM SDVMT100D LFT GSP

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40201097
Hospital Revenue Code	278
Min. Negotiated Rate	$157.00
Max. Negotiated Rate	$157.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$157.00
Rate for Payer: Hamaspik Choice Inc Medicare	$157.00

5HLE L PLTE5MM SDVMT100D LFT GSP

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40201097
Hospital Revenue Code	278
Min. Negotiated Rate	$109.90
Max. Negotiated Rate	$329.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$172.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$188.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$157.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$180.55
Rate for Payer: EmblemHealth Commercial	$157.00
Rate for Payer: Fidelis Medicare Advantage	$329.70
Rate for Payer: Group Health Inc Commercial	$157.00
Rate for Payer: Group Health Inc Medicare	$109.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$157.00
Rate for Payer: Hamaspik Choice Inc Medicare	$157.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$204.10

5H L-PLATE LEFT W/8MM BAR

Facility

$502.00

Service Code	HCPCS C1713
Hospital Charge Code	40202246
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$527.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$276.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$301.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$251.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$288.65
Rate for Payer: EmblemHealth Commercial	$251.00
Rate for Payer: Fidelis Medicare Advantage	$527.10
Rate for Payer: Group Health Inc Commercial	$251.00
Rate for Payer: Group Health Inc Medicare	$175.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$251.00
Rate for Payer: Hamaspik Choice Inc Medicare	$251.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$326.30

5H L-PLATE LEFT W/8MM BAR

Facility

$502.00

Service Code	HCPCS C1713
Hospital Charge Code	40202246
Hospital Revenue Code	278
Min. Negotiated Rate	$251.00
Max. Negotiated Rate	$251.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$251.00
Rate for Payer: Hamaspik Choice Inc Medicare	$251.00

5H L-PLATE, RIGHT W/8MM BAR

Facility

$502.00

Service Code	HCPCS C1713
Hospital Charge Code	40202247
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$527.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$276.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$301.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$251.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$288.65
Rate for Payer: EmblemHealth Commercial	$251.00
Rate for Payer: Fidelis Medicare Advantage	$527.10
Rate for Payer: Group Health Inc Commercial	$251.00
Rate for Payer: Group Health Inc Medicare	$175.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$251.00
Rate for Payer: Hamaspik Choice Inc Medicare	$251.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$326.30

5H L-PLATE, RIGHT W/8MM BAR

Facility

$502.00

Service Code	HCPCS C1713
Hospital Charge Code	40202247
Hospital Revenue Code	278
Min. Negotiated Rate	$251.00
Max. Negotiated Rate	$251.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$251.00
Rate for Payer: Hamaspik Choice Inc Medicare	$251.00

5H L PLT,2MM ADV MDFC LOC

Facility

$354.00

Service Code	HCPCS C1713
Hospital Charge Code	40202240
Hospital Revenue Code	278
Min. Negotiated Rate	$123.90
Max. Negotiated Rate	$371.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$194.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$212.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$177.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$203.55
Rate for Payer: EmblemHealth Commercial	$177.00
Rate for Payer: Fidelis Medicare Advantage	$371.70
Rate for Payer: Group Health Inc Commercial	$177.00
Rate for Payer: Group Health Inc Medicare	$123.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$177.00
Rate for Payer: Hamaspik Choice Inc Medicare	$177.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$230.10

5H L PLT,2MM ADV MDFC LOC

Facility

$354.00

Service Code	HCPCS C1713
Hospital Charge Code	40202240
Hospital Revenue Code	278
Min. Negotiated Rate	$177.00
Max. Negotiated Rate	$177.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$177.00
Rate for Payer: Hamaspik Choice Inc Medicare	$177.00

5H L PLT, 5MM ADV MDFC LOC

Facility

$376.00

Service Code	HCPCS C1713
Hospital Charge Code	40202241
Hospital Revenue Code	278
Min. Negotiated Rate	$131.60
Max. Negotiated Rate	$394.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$206.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$225.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$188.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$216.20
Rate for Payer: EmblemHealth Commercial	$188.00
Rate for Payer: Fidelis Medicare Advantage	$394.80
Rate for Payer: Group Health Inc Commercial	$188.00
Rate for Payer: Group Health Inc Medicare	$131.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$188.00
Rate for Payer: Hamaspik Choice Inc Medicare	$188.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$244.40

5H L PLT, 5MM ADV MDFC LOC

Facility

$376.00

Service Code	HCPCS C1713
Hospital Charge Code	40202241
Hospital Revenue Code	278
Min. Negotiated Rate	$188.00
Max. Negotiated Rate	$188.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$188.00
Rate for Payer: Hamaspik Choice Inc Medicare	$188.00

5H L PLTE 2MM ADV MDFC LOC

Facility

$354.00

Service Code	HCPCS C1713
Hospital Charge Code	40202393
Hospital Revenue Code	278
Min. Negotiated Rate	$177.00
Max. Negotiated Rate	$177.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$177.00
Rate for Payer: Hamaspik Choice Inc Medicare	$177.00

5H L PLTE 2MM ADV MDFC LOC

Facility

$354.00

Service Code	HCPCS C1713
Hospital Charge Code	40202393
Hospital Revenue Code	278
Min. Negotiated Rate	$123.90
Max. Negotiated Rate	$371.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$194.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$212.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$177.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$203.55
Rate for Payer: EmblemHealth Commercial	$177.00
Rate for Payer: Fidelis Medicare Advantage	$371.70
Rate for Payer: Group Health Inc Commercial	$177.00
Rate for Payer: Group Health Inc Medicare	$123.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$177.00
Rate for Payer: Hamaspik Choice Inc Medicare	$177.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$230.10

5 H L PLTE 5MM ADV MDFC LOC

Facility

$376.00

Service Code	HCPCS C1713
Hospital Charge Code	40202394
Hospital Revenue Code	278
Min. Negotiated Rate	$131.60
Max. Negotiated Rate	$394.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$206.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$225.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$188.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$216.20
Rate for Payer: EmblemHealth Commercial	$188.00
Rate for Payer: Fidelis Medicare Advantage	$394.80
Rate for Payer: Group Health Inc Commercial	$188.00
Rate for Payer: Group Health Inc Medicare	$131.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$188.00
Rate for Payer: Hamaspik Choice Inc Medicare	$188.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$244.40

5 H L PLTE 5MM ADV MDFC LOC

Facility

$376.00

Service Code	HCPCS C1713
Hospital Charge Code	40202394
Hospital Revenue Code	278
Min. Negotiated Rate	$188.00
Max. Negotiated Rate	$188.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$188.00
Rate for Payer: Hamaspik Choice Inc Medicare	$188.00

5 H L PT 2MM ADVC 100D LT STD

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40202396
Hospital Revenue Code	278
Min. Negotiated Rate	$157.00
Max. Negotiated Rate	$157.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$157.00
Rate for Payer: Hamaspik Choice Inc Medicare	$157.00

5 H L PT 2MM ADVC 100D LT STD

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40202396
Hospital Revenue Code	278
Min. Negotiated Rate	$109.90
Max. Negotiated Rate	$329.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$172.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$188.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$157.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$180.55
Rate for Payer: EmblemHealth Commercial	$157.00
Rate for Payer: Fidelis Medicare Advantage	$329.70
Rate for Payer: Group Health Inc Commercial	$157.00
Rate for Payer: Group Health Inc Medicare	$109.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$157.00
Rate for Payer: Hamaspik Choice Inc Medicare	$157.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$204.10

5H L PT 2MM ADVC 100D LT STD

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40202243
Hospital Revenue Code	278
Min. Negotiated Rate	$109.90
Max. Negotiated Rate	$329.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$172.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$188.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$157.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$180.55
Rate for Payer: EmblemHealth Commercial	$157.00
Rate for Payer: Fidelis Medicare Advantage	$329.70
Rate for Payer: Group Health Inc Commercial	$157.00
Rate for Payer: Group Health Inc Medicare	$109.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$157.00
Rate for Payer: Hamaspik Choice Inc Medicare	$157.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$204.10

5H L PT 2MM ADVC 100D LT STD

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40202243
Hospital Revenue Code	278
Min. Negotiated Rate	$157.00
Max. Negotiated Rate	$157.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$157.00
Rate for Payer: Hamaspik Choice Inc Medicare	$157.00

5 H L PT 2MM ADVC 100D RT STD

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40202397
Hospital Revenue Code	278
Min. Negotiated Rate	$157.00
Max. Negotiated Rate	$157.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$157.00
Rate for Payer: Hamaspik Choice Inc Medicare	$157.00

Know your out-of-pocket cost for care.

All Charges