St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

GORE-TEX GRFT VASCULAR V47040L

Facility

$1,170.00

Service Code	HCPCS C1768
Hospital Charge Code	40209962
Hospital Revenue Code	278
Min. Negotiated Rate	$322.77
Max. Negotiated Rate	$1,228.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$643.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Brighton Health Commercial	$702.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$585.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$672.75
Rate for Payer: EmblemHealth Commercial	$585.00
Rate for Payer: Fidelis Medicare Advantage	$1,228.50
Rate for Payer: Group Health Inc Commercial	$585.00
Rate for Payer: Group Health Inc Medicare	$409.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$585.00
Rate for Payer: Hamaspik Choice Inc Medicare	$585.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$760.50

GORE-TEX GRFT VASCULAR V47040L

Facility

$1,170.00

Service Code	HCPCS C1768
Hospital Charge Code	40209962
Hospital Revenue Code	278
Min. Negotiated Rate	$585.00
Max. Negotiated Rate	$585.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$585.00
Rate for Payer: Hamaspik Choice Inc Medicare	$585.00

GORETEX PATCH

Facility

$519.52

Hospital Charge Code	40207007
Hospital Revenue Code	270
Min. Negotiated Rate	$181.83
Max. Negotiated Rate	$415.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$285.74
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$259.76
Rate for Payer: Aetna Government	$259.76
Rate for Payer: Brighton Health Commercial	$389.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$415.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$353.27
Rate for Payer: Group Health Inc Commercial	$259.76
Rate for Payer: Group Health Inc Medicare	$181.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$259.76
Rate for Payer: Hamaspik Choice Inc Medicare	$259.76

GORE-TEX PATCH CARDIOVASCULAR

Facility

$546.00

Service Code	HCPCS C1762
Hospital Charge Code	40209353
Hospital Revenue Code	278
Min. Negotiated Rate	$191.10
Max. Negotiated Rate	$1,879.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$300.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,879.82
Rate for Payer: Aetna Government	$1,879.82
Rate for Payer: Brighton Health Commercial	$327.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$273.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$313.95
Rate for Payer: EmblemHealth Commercial	$273.00
Rate for Payer: Fidelis Medicare Advantage	$573.30
Rate for Payer: Group Health Inc Commercial	$273.00
Rate for Payer: Group Health Inc Medicare	$191.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$273.00
Rate for Payer: Hamaspik Choice Inc Medicare	$273.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$354.90

GORE-TEX PATCH CARDIOVASCULAR

Facility

$546.00

Service Code	HCPCS C1762
Hospital Charge Code	40209353
Hospital Revenue Code	278
Min. Negotiated Rate	$273.00
Max. Negotiated Rate	$273.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$273.00
Rate for Payer: Hamaspik Choice Inc Medicare	$273.00

GORE-TEX VASCULAR GRAFT(S47045)

Facility

$1,238.00

Service Code	HCPCS C1768
Hospital Charge Code	40205244
Hospital Revenue Code	278
Min. Negotiated Rate	$322.77
Max. Negotiated Rate	$1,299.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$680.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Brighton Health Commercial	$742.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$619.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$711.85
Rate for Payer: EmblemHealth Commercial	$619.00
Rate for Payer: Fidelis Medicare Advantage	$1,299.90
Rate for Payer: Group Health Inc Commercial	$619.00
Rate for Payer: Group Health Inc Medicare	$433.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$619.00
Rate for Payer: Hamaspik Choice Inc Medicare	$619.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$804.70

GORE-TEX VASCULAR GRAFT(S47045)

Facility

$1,238.00

Service Code	HCPCS C1768
Hospital Charge Code	40205244
Hospital Revenue Code	278
Min. Negotiated Rate	$619.00
Max. Negotiated Rate	$619.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$619.00
Rate for Payer: Hamaspik Choice Inc Medicare	$619.00

GORE VIABAH ENDO PROS. 7FR

Facility

$5,540.00

Service Code	HCPCS C1874
Hospital Charge Code	40206290
Hospital Revenue Code	278
Min. Negotiated Rate	$2,770.00
Max. Negotiated Rate	$2,770.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,770.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,770.00

GORE VIABAH ENDO PROS. 7FR

Facility

$5,540.00

Service Code	HCPCS C1874
Hospital Charge Code	40206290
Hospital Revenue Code	278
Min. Negotiated Rate	$265.52
Max. Negotiated Rate	$5,817.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,047.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$265.52
Rate for Payer: Aetna Government	$265.52
Rate for Payer: Brighton Health Commercial	$3,324.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,770.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,185.50
Rate for Payer: EmblemHealth Commercial	$2,770.00
Rate for Payer: Fidelis Medicare Advantage	$5,817.00
Rate for Payer: Group Health Inc Commercial	$2,770.00
Rate for Payer: Group Health Inc Medicare	$1,939.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,770.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,770.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,601.00

GORE VIABAHN BLN EXPANDA

Facility

$6,672.00

Service Code	HCPCS C1776
Hospital Charge Code	40009289
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$7,005.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,669.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$4,003.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,336.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,836.40
Rate for Payer: EmblemHealth Commercial	$3,336.00
Rate for Payer: Fidelis Medicare Advantage	$7,005.60
Rate for Payer: Group Health Inc Commercial	$3,336.00
Rate for Payer: Group Health Inc Medicare	$2,335.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,336.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,336.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,336.80

GORE VIABAHN BLN EXPANDA

Facility

$6,672.00

Service Code	HCPCS C1776
Hospital Charge Code	40009289
Hospital Revenue Code	278
Min. Negotiated Rate	$3,336.00
Max. Negotiated Rate	$3,336.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,336.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,336.00

GORE VIABAHN ENDO/PROSTHESIS

Facility

$6,540.00

Service Code	HCPCS C1874
Hospital Charge Code	40209601
Hospital Revenue Code	278
Min. Negotiated Rate	$3,270.00
Max. Negotiated Rate	$3,270.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,270.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,270.00

GORE VIABAHN ENDO/PROSTHESIS

Facility

$6,540.00

Service Code	HCPCS C1874
Hospital Charge Code	40209601
Hospital Revenue Code	278
Min. Negotiated Rate	$265.52
Max. Negotiated Rate	$6,867.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,597.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$265.52
Rate for Payer: Aetna Government	$265.52
Rate for Payer: Brighton Health Commercial	$3,924.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,270.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,760.50
Rate for Payer: EmblemHealth Commercial	$3,270.00
Rate for Payer: Fidelis Medicare Advantage	$6,867.00
Rate for Payer: Group Health Inc Commercial	$3,270.00
Rate for Payer: Group Health Inc Medicare	$2,289.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,270.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,270.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,251.00

GOR-TEX PATCH CARDVASCULAR

Facility

$484.00

Service Code	HCPCS C1768
Hospital Charge Code	40205514
Hospital Revenue Code	278
Min. Negotiated Rate	$169.40
Max. Negotiated Rate	$508.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$266.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Brighton Health Commercial	$290.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$242.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$278.30
Rate for Payer: EmblemHealth Commercial	$242.00
Rate for Payer: Fidelis Medicare Advantage	$508.20
Rate for Payer: Group Health Inc Commercial	$242.00
Rate for Payer: Group Health Inc Medicare	$169.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$242.00
Rate for Payer: Hamaspik Choice Inc Medicare	$242.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$314.60

GOR-TEX PATCH CARDVASCULAR

Facility

$484.00

Service Code	HCPCS C1768
Hospital Charge Code	40205514
Hospital Revenue Code	278
Min. Negotiated Rate	$242.00
Max. Negotiated Rate	$242.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$242.00
Rate for Payer: Hamaspik Choice Inc Medicare	$242.00

GRAFT BIFURCATD HEMASHIELD 085147

Facility

$635.00

Service Code	HCPCS C1768
Hospital Charge Code	64906375
Hospital Revenue Code	278
Min. Negotiated Rate	$222.25
Max. Negotiated Rate	$666.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$349.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Brighton Health Commercial	$381.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$317.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$365.12
Rate for Payer: EmblemHealth Commercial	$317.50
Rate for Payer: Fidelis Medicare Advantage	$666.75
Rate for Payer: Group Health Inc Commercial	$317.50
Rate for Payer: Group Health Inc Medicare	$222.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$317.50
Rate for Payer: Hamaspik Choice Inc Medicare	$317.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$412.75

GRAFT BIFURCATD HEMASHIELD 085147

Facility

$635.00

Service Code	HCPCS C1768
Hospital Charge Code	64906375
Hospital Revenue Code	278
Min. Negotiated Rate	$317.50
Max. Negotiated Rate	$317.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$317.50
Rate for Payer: Hamaspik Choice Inc Medicare	$317.50

GRAFT BONE CERVICAL 6MM

Facility

$2,280.00

Service Code	HCPCS C1768
Hospital Charge Code	40200515
Hospital Revenue Code	278
Min. Negotiated Rate	$322.77
Max. Negotiated Rate	$2,394.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,254.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Brighton Health Commercial	$1,368.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,140.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,311.00
Rate for Payer: EmblemHealth Commercial	$1,140.00
Rate for Payer: Fidelis Medicare Advantage	$2,394.00
Rate for Payer: Group Health Inc Commercial	$1,140.00
Rate for Payer: Group Health Inc Medicare	$798.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,140.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,140.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,482.00

GRAFT BONE CERVICAL 6MM

Facility

$2,280.00

Service Code	HCPCS C1768
Hospital Charge Code	40200515
Hospital Revenue Code	278
Min. Negotiated Rate	$1,140.00
Max. Negotiated Rate	$1,140.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,140.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,140.00

GRAFT DURA GEN MATRIX DURAL 4X5

Facility

$110.13

Service Code	HCPCS Q4108
Hospital Charge Code	64901300
Hospital Revenue Code	636
Min. Negotiated Rate	$36.75
Max. Negotiated Rate	$71.58
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$60.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$36.75
Rate for Payer: Aetna Government	$36.75
Rate for Payer: Brighton Health Commercial	$66.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$55.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$63.32
Rate for Payer: Group Health Inc Commercial	$55.06
Rate for Payer: Group Health Inc Medicare	$38.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$55.06
Rate for Payer: Hamaspik Choice Inc Medicare	$55.06
Rate for Payer: SOMOS CHP/HARP/Medicaid	$52.66
Rate for Payer: SOMOS Essential	$52.66
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$71.58

GRAFT DURA GEN MATRIX DURAL 4X5

Facility

$2,182.00

Service Code	HCPCS C1768
Hospital Charge Code	40209715
Hospital Revenue Code	278
Min. Negotiated Rate	$322.77
Max. Negotiated Rate	$2,291.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,200.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Brighton Health Commercial	$1,309.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,091.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,254.65
Rate for Payer: EmblemHealth Commercial	$1,091.00
Rate for Payer: Fidelis Medicare Advantage	$2,291.10
Rate for Payer: Group Health Inc Commercial	$1,091.00
Rate for Payer: Group Health Inc Medicare	$763.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,091.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,091.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,418.30

GRAFT DURA GEN MATRIX DURAL 4X5

Facility

$110.13

Service Code	HCPCS Q4108
Hospital Charge Code	64901300
Hospital Revenue Code	636
Min. Negotiated Rate	$55.06
Max. Negotiated Rate	$55.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$55.06
Rate for Payer: Hamaspik Choice Inc Medicare	$55.06

GRAFT DURA GEN MATRIX DURAL 4X5

Facility

$2,182.00

Service Code	HCPCS C1768
Hospital Charge Code	40209715
Hospital Revenue Code	278
Min. Negotiated Rate	$1,091.00
Max. Negotiated Rate	$1,091.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,091.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,091.00

GRAFT DURAL 8X12 DURAGN PERICRD

Facility

$770.00

Service Code	HCPCS C1768
Hospital Charge Code	64906224
Hospital Revenue Code	278
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$385.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$385.00
Rate for Payer: Hamaspik Choice Inc Medicare	$385.00

GRAFT DURAL 8X12 DURAGN PERICRD

Facility

$770.00

Service Code	HCPCS C1768
Hospital Charge Code	64906224
Hospital Revenue Code	278
Min. Negotiated Rate	$269.50
Max. Negotiated Rate	$808.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$423.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Brighton Health Commercial	$462.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$385.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$442.75
Rate for Payer: EmblemHealth Commercial	$385.00
Rate for Payer: Fidelis Medicare Advantage	$808.50
Rate for Payer: Group Health Inc Commercial	$385.00
Rate for Payer: Group Health Inc Medicare	$269.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$385.00
Rate for Payer: Hamaspik Choice Inc Medicare	$385.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$500.50

Know your out-of-pocket cost for care.

All Charges