St. Barnabas Hospital

All Charges

Charge

Type

Price

CC C/WIRE AB A G/S .014(300CM)

Facility IP

$200.00

Service Code	HCPCS C1769
Hospital Charge Code	66529120
Hospital Revenue Code	278
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$100.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$100.00

CC C/WIRE AB A G/S .014(300CM)

Facility OP

$200.00

Service Code	HCPCS C1769
Hospital Charge Code	66529120
Hospital Revenue Code	278
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$210.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$110.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.08
Rate for Payer: Aetna Government	$4.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$100.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$115.00
Rate for Payer: Fidelis Medicare Advantage	$210.00
Rate for Payer: Group Health Inc Commercial	$100.00
Rate for Payer: Group Health Inc Medicare	$70.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$100.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$130.00

CC C/WIRE AB ASAHI .014X180CM

Facility IP

$200.00

Service Code	HCPCS C1769
Hospital Charge Code	66528984
Hospital Revenue Code	278
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$100.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$100.00

CC C/WIRE AB ASAHI .014X180CM

Facility OP

$200.00

Service Code	HCPCS C1769
Hospital Charge Code	66528984
Hospital Revenue Code	278
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$210.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$110.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.08
Rate for Payer: Aetna Government	$4.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$100.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$115.00
Rate for Payer: Fidelis Medicare Advantage	$210.00
Rate for Payer: Group Health Inc Commercial	$100.00
Rate for Payer: Group Health Inc Medicare	$70.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$100.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$130.00

CC C/WIRE ABBOTT .014 190-300CM

Facility IP

$200.00

Service Code	HCPCS C1769
Hospital Charge Code	66522115
Hospital Revenue Code	278
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$100.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$100.00

CC C/WIRE ABBOTT .014 190-300CM

Facility OP

$200.00

Service Code	HCPCS C1769
Hospital Charge Code	66522115
Hospital Revenue Code	278
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$210.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$110.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.08
Rate for Payer: Aetna Government	$4.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$100.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$115.00
Rate for Payer: Fidelis Medicare Advantage	$210.00
Rate for Payer: Group Health Inc Commercial	$100.00
Rate for Payer: Group Health Inc Medicare	$70.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$100.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$130.00

CC C/WIRE ABBOTT BAL HT .014

Facility IP

$200.00

Service Code	HCPCS C1769
Hospital Charge Code	66522105
Hospital Revenue Code	278
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$100.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$100.00

CC C/WIRE ABBOTT BAL HT .014

Facility OP

$200.00

Service Code	HCPCS C1769
Hospital Charge Code	66522105
Hospital Revenue Code	278
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$210.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$110.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.08
Rate for Payer: Aetna Government	$4.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$100.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$115.00
Rate for Payer: Fidelis Medicare Advantage	$210.00
Rate for Payer: Group Health Inc Commercial	$100.00
Rate for Payer: Group Health Inc Medicare	$70.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$100.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$130.00

CC C/WIRE AB MIRACLEB3 .014190CM

Facility IP

$370.00

Service Code	HCPCS C1769
Hospital Charge Code	66529121
Hospital Revenue Code	278
Min. Negotiated Rate	$185.00
Max. Negotiated Rate	$185.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$185.00
Rate for Payer: Hamaspik Choice Inc Medicare	$185.00

CC C/WIRE AB MIRACLEB3 .014190CM

Facility OP

$370.00

Service Code	HCPCS C1769
Hospital Charge Code	66529121
Hospital Revenue Code	278
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$388.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$203.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.08
Rate for Payer: Aetna Government	$4.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$185.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$212.75
Rate for Payer: Fidelis Medicare Advantage	$388.50
Rate for Payer: Group Health Inc Commercial	$185.00
Rate for Payer: Group Health Inc Medicare	$129.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$185.00
Rate for Payer: Hamaspik Choice Inc Medicare	$185.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$240.50

CC C/WIRE AB MIRACLEB3 .014 300CM

Facility OP

$370.00

Service Code	HCPCS C1769
Hospital Charge Code	66529122
Hospital Revenue Code	278
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$388.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$203.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.08
Rate for Payer: Aetna Government	$4.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$185.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$212.75
Rate for Payer: Fidelis Medicare Advantage	$388.50
Rate for Payer: Group Health Inc Commercial	$185.00
Rate for Payer: Group Health Inc Medicare	$129.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$185.00
Rate for Payer: Hamaspik Choice Inc Medicare	$185.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$240.50

CC C/WIRE AB MIRACLEB3 .014 300CM

Facility IP

$370.00

Service Code	HCPCS C1769
Hospital Charge Code	66529122
Hospital Revenue Code	278
Min. Negotiated Rate	$185.00
Max. Negotiated Rate	$185.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$185.00
Rate for Payer: Hamaspik Choice Inc Medicare	$185.00

CC C/WIRE AB PROWATER .014 180CM

Facility IP

$200.00

Service Code	HCPCS C1769
Hospital Charge Code	66529123
Hospital Revenue Code	278
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$100.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$100.00

CC C/WIRE AB PROWATER .014 180CM

Facility OP

$200.00

Service Code	HCPCS C1769
Hospital Charge Code	66529123
Hospital Revenue Code	278
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$210.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$110.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.08
Rate for Payer: Aetna Government	$4.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$100.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$115.00
Rate for Payer: Fidelis Medicare Advantage	$210.00
Rate for Payer: Group Health Inc Commercial	$100.00
Rate for Payer: Group Health Inc Medicare	$70.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$100.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$130.00

CC C/WIRE AB PROWATER .014 300CM

Facility OP

$200.00

Service Code	HCPCS C1769
Hospital Charge Code	66529124
Hospital Revenue Code	278
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$210.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$110.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.08
Rate for Payer: Aetna Government	$4.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$100.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$115.00
Rate for Payer: Fidelis Medicare Advantage	$210.00
Rate for Payer: Group Health Inc Commercial	$100.00
Rate for Payer: Group Health Inc Medicare	$70.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$100.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$130.00

CC C/WIRE AB PROWATER .014 300CM

Facility IP

$200.00

Service Code	HCPCS C1769
Hospital Charge Code	66529124
Hospital Revenue Code	278
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$100.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.00
Rate for Payer: Hamaspik Choice Inc Medicare	$100.00

CC D/CATH 5F BOSTON AR 1

Facility OP

$34.00

Service Code	HCPCS C1725
Hospital Charge Code	66520100
Hospital Revenue Code	278
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$44.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$18.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.85
Rate for Payer: Aetna Government	$44.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$17.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$19.55
Rate for Payer: Fidelis Medicare Advantage	$35.70
Rate for Payer: Group Health Inc Commercial	$17.00
Rate for Payer: Group Health Inc Medicare	$11.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$17.00
Rate for Payer: Hamaspik Choice Inc Medicare	$17.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$22.10

CC D/CATH 5F BOSTON AR 1

Facility IP

$34.00

Service Code	HCPCS C1725
Hospital Charge Code	66520100
Hospital Revenue Code	278
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$17.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$17.00
Rate for Payer: Hamaspik Choice Inc Medicare	$17.00

CC D/ CATH 5F BOSTON AR 2

Facility OP

$44.80

Service Code	HCPCS C1725
Hospital Charge Code	66520102
Hospital Revenue Code	278
Min. Negotiated Rate	$15.68
Max. Negotiated Rate	$47.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$24.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.85
Rate for Payer: Aetna Government	$44.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$22.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$25.76
Rate for Payer: Fidelis Medicare Advantage	$47.04
Rate for Payer: Group Health Inc Commercial	$22.40
Rate for Payer: Group Health Inc Medicare	$15.68
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.40
Rate for Payer: Hamaspik Choice Inc Medicare	$22.40
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$29.12

CC D/ CATH 5F BOSTON AR 2

Facility IP

$44.80

Service Code	HCPCS C1725
Hospital Charge Code	66520102
Hospital Revenue Code	278
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$22.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.40
Rate for Payer: Hamaspik Choice Inc Medicare	$22.40

CC D/CATH 5F BOSTON IM

Facility OP

$44.80

Service Code	HCPCS C1725
Hospital Charge Code	66520103
Hospital Revenue Code	278
Min. Negotiated Rate	$15.68
Max. Negotiated Rate	$47.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$24.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.85
Rate for Payer: Aetna Government	$44.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$22.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$25.76
Rate for Payer: Fidelis Medicare Advantage	$47.04
Rate for Payer: Group Health Inc Commercial	$22.40
Rate for Payer: Group Health Inc Medicare	$15.68
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.40
Rate for Payer: Hamaspik Choice Inc Medicare	$22.40
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$29.12

CC D/CATH 5F BOSTON IM

Facility IP

$44.80

Service Code	HCPCS C1725
Hospital Charge Code	66520103
Hospital Revenue Code	278
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$22.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.40
Rate for Payer: Hamaspik Choice Inc Medicare	$22.40

CC D/CATH 5F BOSTON RCB

Facility IP

$44.80

Service Code	HCPCS C1725
Hospital Charge Code	66520104
Hospital Revenue Code	278
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$22.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.40
Rate for Payer: Hamaspik Choice Inc Medicare	$22.40

CC D/CATH 5F BOSTON RCB

Facility OP

$44.80

Service Code	HCPCS C1725
Hospital Charge Code	66520104
Hospital Revenue Code	278
Min. Negotiated Rate	$15.68
Max. Negotiated Rate	$47.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$24.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.85
Rate for Payer: Aetna Government	$44.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$22.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$25.76
Rate for Payer: Fidelis Medicare Advantage	$47.04
Rate for Payer: Group Health Inc Commercial	$22.40
Rate for Payer: Group Health Inc Medicare	$15.68
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.40
Rate for Payer: Hamaspik Choice Inc Medicare	$22.40
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$29.12

CC D/CATH 6F CORDIS JL 4.0 100CM

Facility OP

$44.00

Service Code	HCPCS C1725
Hospital Charge Code	66520105
Hospital Revenue Code	278
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$46.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$24.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.85
Rate for Payer: Aetna Government	$44.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$22.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$25.30
Rate for Payer: Fidelis Medicare Advantage	$46.20
Rate for Payer: Group Health Inc Commercial	$22.00
Rate for Payer: Group Health Inc Medicare	$15.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.00
Rate for Payer: Hamaspik Choice Inc Medicare	$22.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$28.60

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