St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

CC BMS AB VISION ML RX3.0MMX28MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528931
Hospital Revenue Code	278
Min. Negotiated Rate	$398.18
Max. Negotiated Rate	$2,047.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,072.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$398.18
Rate for Payer: Aetna Government	$398.18
Rate for Payer: Brighton Health Commercial	$1,170.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$975.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,121.25
Rate for Payer: EmblemHealth Commercial	$975.00
Rate for Payer: Fidelis Medicare Advantage	$2,047.50
Rate for Payer: Group Health Inc Commercial	$975.00
Rate for Payer: Group Health Inc Medicare	$682.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,267.50

CC BMS AB VISION ML RX 3.0X8MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528932
Hospital Revenue Code	278
Min. Negotiated Rate	$398.18
Max. Negotiated Rate	$2,047.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,072.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$398.18
Rate for Payer: Aetna Government	$398.18
Rate for Payer: Brighton Health Commercial	$1,170.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$975.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,121.25
Rate for Payer: EmblemHealth Commercial	$975.00
Rate for Payer: Fidelis Medicare Advantage	$2,047.50
Rate for Payer: Group Health Inc Commercial	$975.00
Rate for Payer: Group Health Inc Medicare	$682.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,267.50

CC BMS AB VISION ML RX 3.0X8MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528932
Hospital Revenue Code	278
Min. Negotiated Rate	$975.00
Max. Negotiated Rate	$975.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00

CC BMS AB VISION ML RX3.5MMX15

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528934
Hospital Revenue Code	278
Min. Negotiated Rate	$975.00
Max. Negotiated Rate	$975.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00

CC BMS AB VISION ML RX3.5MMX15

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528934
Hospital Revenue Code	278
Min. Negotiated Rate	$398.18
Max. Negotiated Rate	$2,047.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,072.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$398.18
Rate for Payer: Aetna Government	$398.18
Rate for Payer: Brighton Health Commercial	$1,170.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$975.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,121.25
Rate for Payer: EmblemHealth Commercial	$975.00
Rate for Payer: Fidelis Medicare Advantage	$2,047.50
Rate for Payer: Group Health Inc Commercial	$975.00
Rate for Payer: Group Health Inc Medicare	$682.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,267.50

CC BMS AB VISION ML RX 3.5MMX18MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528935
Hospital Revenue Code	278
Min. Negotiated Rate	$398.18
Max. Negotiated Rate	$2,047.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,072.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$398.18
Rate for Payer: Aetna Government	$398.18
Rate for Payer: Brighton Health Commercial	$1,170.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$975.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,121.25
Rate for Payer: EmblemHealth Commercial	$975.00
Rate for Payer: Fidelis Medicare Advantage	$2,047.50
Rate for Payer: Group Health Inc Commercial	$975.00
Rate for Payer: Group Health Inc Medicare	$682.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,267.50

CC BMS AB VISION ML RX 3.5MMX18MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528935
Hospital Revenue Code	278
Min. Negotiated Rate	$975.00
Max. Negotiated Rate	$975.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00

CC BMS AB VISION ML RX 3.5MMX23MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528936
Hospital Revenue Code	278
Min. Negotiated Rate	$398.18
Max. Negotiated Rate	$2,047.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,072.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$398.18
Rate for Payer: Aetna Government	$398.18
Rate for Payer: Brighton Health Commercial	$1,170.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$975.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,121.25
Rate for Payer: EmblemHealth Commercial	$975.00
Rate for Payer: Fidelis Medicare Advantage	$2,047.50
Rate for Payer: Group Health Inc Commercial	$975.00
Rate for Payer: Group Health Inc Medicare	$682.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,267.50

CC BMS AB VISION ML RX 3.5MMX23MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528936
Hospital Revenue Code	278
Min. Negotiated Rate	$975.00
Max. Negotiated Rate	$975.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00

CC BMS AB VISION ML RX3.5MMX28MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528937
Hospital Revenue Code	278
Min. Negotiated Rate	$398.18
Max. Negotiated Rate	$2,047.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,072.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$398.18
Rate for Payer: Aetna Government	$398.18
Rate for Payer: Brighton Health Commercial	$1,170.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$975.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,121.25
Rate for Payer: EmblemHealth Commercial	$975.00
Rate for Payer: Fidelis Medicare Advantage	$2,047.50
Rate for Payer: Group Health Inc Commercial	$975.00
Rate for Payer: Group Health Inc Medicare	$682.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,267.50

CC BMS AB VISION ML RX3.5MMX28MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528937
Hospital Revenue Code	278
Min. Negotiated Rate	$975.00
Max. Negotiated Rate	$975.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00

CC BMS AB VISION ML RX3.5MMX8MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528938
Hospital Revenue Code	278
Min. Negotiated Rate	$398.18
Max. Negotiated Rate	$2,047.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,072.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$398.18
Rate for Payer: Aetna Government	$398.18
Rate for Payer: Brighton Health Commercial	$1,170.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$975.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,121.25
Rate for Payer: EmblemHealth Commercial	$975.00
Rate for Payer: Fidelis Medicare Advantage	$2,047.50
Rate for Payer: Group Health Inc Commercial	$975.00
Rate for Payer: Group Health Inc Medicare	$682.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,267.50

CC BMS AB VISION ML RX3.5MMX8MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528938
Hospital Revenue Code	278
Min. Negotiated Rate	$975.00
Max. Negotiated Rate	$975.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00

CC BMS AB V ML RX 4.0MMX18MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528941
Hospital Revenue Code	278
Min. Negotiated Rate	$975.00
Max. Negotiated Rate	$975.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00

CC BMS AB V ML RX 4.0MMX18MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528941
Hospital Revenue Code	278
Min. Negotiated Rate	$398.18
Max. Negotiated Rate	$2,047.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,072.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$398.18
Rate for Payer: Aetna Government	$398.18
Rate for Payer: Brighton Health Commercial	$1,170.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$975.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,121.25
Rate for Payer: EmblemHealth Commercial	$975.00
Rate for Payer: Fidelis Medicare Advantage	$2,047.50
Rate for Payer: Group Health Inc Commercial	$975.00
Rate for Payer: Group Health Inc Medicare	$682.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,267.50

CC BMS AB V ML RX 4.0MMX23MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528942
Hospital Revenue Code	278
Min. Negotiated Rate	$398.18
Max. Negotiated Rate	$2,047.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,072.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$398.18
Rate for Payer: Aetna Government	$398.18
Rate for Payer: Brighton Health Commercial	$1,170.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$975.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,121.25
Rate for Payer: EmblemHealth Commercial	$975.00
Rate for Payer: Fidelis Medicare Advantage	$2,047.50
Rate for Payer: Group Health Inc Commercial	$975.00
Rate for Payer: Group Health Inc Medicare	$682.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,267.50

CC BMS AB V ML RX 4.0MMX23MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528942
Hospital Revenue Code	278
Min. Negotiated Rate	$975.00
Max. Negotiated Rate	$975.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00

CC BMS AB V ML RX 4.0MMX28MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528943
Hospital Revenue Code	278
Min. Negotiated Rate	$398.18
Max. Negotiated Rate	$2,047.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,072.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$398.18
Rate for Payer: Aetna Government	$398.18
Rate for Payer: Brighton Health Commercial	$1,170.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$975.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,121.25
Rate for Payer: EmblemHealth Commercial	$975.00
Rate for Payer: Fidelis Medicare Advantage	$2,047.50
Rate for Payer: Group Health Inc Commercial	$975.00
Rate for Payer: Group Health Inc Medicare	$682.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,267.50

CC BMS AB V ML RX 4.0MMX28MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528943
Hospital Revenue Code	278
Min. Negotiated Rate	$975.00
Max. Negotiated Rate	$975.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00

CC BMS AB V ML RX 4.0MMX8MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528944
Hospital Revenue Code	278
Min. Negotiated Rate	$398.18
Max. Negotiated Rate	$2,047.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,072.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$398.18
Rate for Payer: Aetna Government	$398.18
Rate for Payer: Brighton Health Commercial	$1,170.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$975.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,121.25
Rate for Payer: EmblemHealth Commercial	$975.00
Rate for Payer: Fidelis Medicare Advantage	$2,047.50
Rate for Payer: Group Health Inc Commercial	$975.00
Rate for Payer: Group Health Inc Medicare	$682.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,267.50

CC BMS AB V ML RX 4.0MMX8MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528944
Hospital Revenue Code	278
Min. Negotiated Rate	$975.00
Max. Negotiated Rate	$975.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00

CC BMS AB V ULTRA 4.5MMX13MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528945
Hospital Revenue Code	278
Min. Negotiated Rate	$398.18
Max. Negotiated Rate	$2,047.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,072.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$398.18
Rate for Payer: Aetna Government	$398.18
Rate for Payer: Brighton Health Commercial	$1,170.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$975.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,121.25
Rate for Payer: EmblemHealth Commercial	$975.00
Rate for Payer: Fidelis Medicare Advantage	$2,047.50
Rate for Payer: Group Health Inc Commercial	$975.00
Rate for Payer: Group Health Inc Medicare	$682.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,267.50

CC BMS AB V ULTRA 4.5MMX13MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528945
Hospital Revenue Code	278
Min. Negotiated Rate	$975.00
Max. Negotiated Rate	$975.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00

CC BMS AB V ULTRA 4.5MMX18MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528946
Hospital Revenue Code	278
Min. Negotiated Rate	$398.18
Max. Negotiated Rate	$2,047.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,072.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$398.18
Rate for Payer: Aetna Government	$398.18
Rate for Payer: Brighton Health Commercial	$1,170.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$975.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,121.25
Rate for Payer: EmblemHealth Commercial	$975.00
Rate for Payer: Fidelis Medicare Advantage	$2,047.50
Rate for Payer: Group Health Inc Commercial	$975.00
Rate for Payer: Group Health Inc Medicare	$682.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,267.50

CC BMS AB V ULTRA 4.5MMX18MM

Facility

$1,950.00

Service Code	HCPCS C1876
Hospital Charge Code	66528946
Hospital Revenue Code	278
Min. Negotiated Rate	$975.00
Max. Negotiated Rate	$975.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$975.00
Rate for Payer: Hamaspik Choice Inc Medicare	$975.00

Know your out-of-pocket cost for care.

All Charges