St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

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

5H L PT 2MM ADVC 100D RT STD

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40202244
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 RT STD

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40202244
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

5H L PT 5MM ADVC 100D LT STD

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40202245
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 5MM ADVC 100D LT STD

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40202245
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 HOLE L PLT 5MM ADVMT 100D RGHT

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40202390
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

5 HOLE L PLT 5MM ADVMT 100D RGHT

Facility

$314.00

Service Code	HCPCS C1713
Hospital Charge Code	40202390
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 HOLE L-PLT LFT EXTND LONG

Facility

$500.00

Service Code	HCPCS C1713
Hospital Charge Code	40200866
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$525.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$275.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$300.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$250.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$287.50
Rate for Payer: EmblemHealth Commercial	$250.00
Rate for Payer: Fidelis Medicare Advantage	$525.00
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$175.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$250.00
Rate for Payer: Hamaspik Choice Inc Medicare	$250.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$325.00

5 HOLE L-PLT LFT EXTND LONG

Facility

$500.00

Service Code	HCPCS C1713
Hospital Charge Code	40200866
Hospital Revenue Code	278
Min. Negotiated Rate	$250.00
Max. Negotiated Rate	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$250.00
Rate for Payer: Hamaspik Choice Inc Medicare	$250.00

5 HOLE L-PLT RIGHT LONG BAR

Facility

$500.00

Service Code	HCPCS C1713
Hospital Charge Code	40200867
Hospital Revenue Code	278
Min. Negotiated Rate	$250.00
Max. Negotiated Rate	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$250.00
Rate for Payer: Hamaspik Choice Inc Medicare	$250.00

5 HOLE L-PLT RIGHT LONG BAR

Facility

$500.00

Service Code	HCPCS C1713
Hospital Charge Code	40200867
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$525.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$275.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$300.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$250.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$287.50
Rate for Payer: EmblemHealth Commercial	$250.00
Rate for Payer: Fidelis Medicare Advantage	$525.00
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$175.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$250.00
Rate for Payer: Hamaspik Choice Inc Medicare	$250.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$325.00

5 HOLE PL,2MM ADV MDFC LOC

Facility

$352.00

Service Code	HCPCS C1713
Hospital Charge Code	40201089
Hospital Revenue Code	278
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$369.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$193.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$211.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$176.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$202.40
Rate for Payer: EmblemHealth Commercial	$176.00
Rate for Payer: Fidelis Medicare Advantage	$369.60
Rate for Payer: Group Health Inc Commercial	$176.00
Rate for Payer: Group Health Inc Medicare	$123.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$176.00
Rate for Payer: Hamaspik Choice Inc Medicare	$176.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$228.80

5 HOLE PL,2MM ADV MDFC LOC

Facility

$352.00

Service Code	HCPCS C1713
Hospital Charge Code	40201089
Hospital Revenue Code	278
Min. Negotiated Rate	$176.00
Max. Negotiated Rate	$176.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$176.00
Rate for Payer: Hamaspik Choice Inc Medicare	$176.00

5 HOLE PLT,5MM ADV MDFC LOC

Facility

$376.00

Service Code	HCPCS C1713
Hospital Charge Code	40201090
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 HOLE PLT,5MM ADV MDFC LOC

Facility

$376.00

Service Code	HCPCS C1713
Hospital Charge Code	40201090
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 HOLE PLT MIDFACE

Facility

$268.00

Service Code	HCPCS C1713
Hospital Charge Code	40201088
Hospital Revenue Code	278
Min. Negotiated Rate	$134.00
Max. Negotiated Rate	$134.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$134.00
Rate for Payer: Hamaspik Choice Inc Medicare	$134.00

5 HOLE PLT MIDFACE

Facility

$268.00

Service Code	HCPCS C1713
Hospital Charge Code	40201088
Hospital Revenue Code	278
Min. Negotiated Rate	$93.80
Max. Negotiated Rate	$281.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$147.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$160.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$134.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$154.10
Rate for Payer: EmblemHealth Commercial	$134.00
Rate for Payer: Fidelis Medicare Advantage	$281.40
Rate for Payer: Group Health Inc Commercial	$134.00
Rate for Payer: Group Health Inc Medicare	$93.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$134.00
Rate for Payer: Hamaspik Choice Inc Medicare	$134.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$174.20

5 HOLE Y PLT W/4MM BAR MDFC

Facility

$282.00

Service Code	HCPCS C1713
Hospital Charge Code	40201091
Hospital Revenue Code	278
Min. Negotiated Rate	$98.70
Max. Negotiated Rate	$296.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$155.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$169.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$141.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$162.15
Rate for Payer: EmblemHealth Commercial	$141.00
Rate for Payer: Fidelis Medicare Advantage	$296.10
Rate for Payer: Group Health Inc Commercial	$141.00
Rate for Payer: Group Health Inc Medicare	$98.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$141.00
Rate for Payer: Hamaspik Choice Inc Medicare	$141.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$183.30

5 HOLE Y PLT W/4MM BAR MDFC

Facility

$282.00

Service Code	HCPCS C1713
Hospital Charge Code	40201091
Hospital Revenue Code	278
Min. Negotiated Rate	$141.00
Max. Negotiated Rate	$141.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$141.00
Rate for Payer: Hamaspik Choice Inc Medicare	$141.00

5H PLATE MIDFACE

Facility

$268.00

Service Code	HCPCS C1713
Hospital Charge Code	40202248
Hospital Revenue Code	278
Min. Negotiated Rate	$93.80
Max. Negotiated Rate	$281.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$147.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$160.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$134.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$154.10
Rate for Payer: EmblemHealth Commercial	$134.00
Rate for Payer: Fidelis Medicare Advantage	$281.40
Rate for Payer: Group Health Inc Commercial	$134.00
Rate for Payer: Group Health Inc Medicare	$93.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$134.00
Rate for Payer: Hamaspik Choice Inc Medicare	$134.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$174.20

5H PLATE MIDFACE

Facility

$268.00

Service Code	HCPCS C1713
Hospital Charge Code	40202248
Hospital Revenue Code	278
Min. Negotiated Rate	$134.00
Max. Negotiated Rate	$134.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$134.00
Rate for Payer: Hamaspik Choice Inc Medicare	$134.00

5H PLATE W/4MM BAR MDFC

Facility

$282.00

Service Code	HCPCS C1713
Hospital Charge Code	40202249
Hospital Revenue Code	278
Min. Negotiated Rate	$141.00
Max. Negotiated Rate	$141.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$141.00
Rate for Payer: Hamaspik Choice Inc Medicare	$141.00

5H PLATE W/4MM BAR MDFC

Facility

$282.00

Service Code	HCPCS C1713
Hospital Charge Code	40202249
Hospital Revenue Code	278
Min. Negotiated Rate	$98.70
Max. Negotiated Rate	$296.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$155.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$169.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$141.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$162.15
Rate for Payer: EmblemHealth Commercial	$141.00
Rate for Payer: Fidelis Medicare Advantage	$296.10
Rate for Payer: Group Health Inc Commercial	$141.00
Rate for Payer: Group Health Inc Medicare	$98.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$141.00
Rate for Payer: Hamaspik Choice Inc Medicare	$141.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$183.30

5H PLATE W/8MM BAR MDFC

Facility

$282.00

Service Code	HCPCS C1713
Hospital Charge Code	40202250
Hospital Revenue Code	278
Min. Negotiated Rate	$141.00
Max. Negotiated Rate	$141.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$141.00
Rate for Payer: Hamaspik Choice Inc Medicare	$141.00

5H PLATE W/8MM BAR MDFC

Facility

$282.00

Service Code	HCPCS C1713
Hospital Charge Code	40202250
Hospital Revenue Code	278
Min. Negotiated Rate	$98.70
Max. Negotiated Rate	$296.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$155.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$169.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$141.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$162.15
Rate for Payer: EmblemHealth Commercial	$141.00
Rate for Payer: Fidelis Medicare Advantage	$296.10
Rate for Payer: Group Health Inc Commercial	$141.00
Rate for Payer: Group Health Inc Medicare	$98.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$141.00
Rate for Payer: Hamaspik Choice Inc Medicare	$141.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$183.30

Know your out-of-pocket cost for care.

All Charges