St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

GRAFT HEMASHIELD KNITTED VELOUR

Facility

$480.00

Service Code	HCPCS C1768
Hospital Charge Code	64901092
Hospital Revenue Code	278
Min. Negotiated Rate	$240.00
Max. Negotiated Rate	$240.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$240.00
Rate for Payer: Hamaspik Choice Inc Medicare	$240.00

GRAFT HEMASHIELD KNITTED VELOUR

Facility

$480.00

Service Code	HCPCS C1768
Hospital Charge Code	64901092
Hospital Revenue Code	278
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$504.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$264.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Brighton Health Commercial	$288.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$240.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$276.00
Rate for Payer: EmblemHealth Commercial	$240.00
Rate for Payer: Fidelis Medicare Advantage	$504.00
Rate for Payer: Group Health Inc Commercial	$240.00
Rate for Payer: Group Health Inc Medicare	$168.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$240.00
Rate for Payer: Hamaspik Choice Inc Medicare	$240.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$312.00

GRAFT HEMASHIELD KNIT/VEL 1X6

Facility

$365.40

Service Code	HCPCS C1768
Hospital Charge Code	40209388
Hospital Revenue Code	278
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$182.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$182.70
Rate for Payer: Hamaspik Choice Inc Medicare	$182.70

GRAFT HEMASHIELD KNIT/VEL 1X6

Facility

$365.40

Service Code	HCPCS C1768
Hospital Charge Code	40209388
Hospital Revenue Code	278
Min. Negotiated Rate	$127.89
Max. Negotiated Rate	$383.67
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$200.97
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Brighton Health Commercial	$219.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$182.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$210.10
Rate for Payer: EmblemHealth Commercial	$182.70
Rate for Payer: Fidelis Medicare Advantage	$383.67
Rate for Payer: Group Health Inc Commercial	$182.70
Rate for Payer: Group Health Inc Medicare	$127.89
Rate for Payer: Hamaspik Choice Inc Medicaid	$182.70
Rate for Payer: Hamaspik Choice Inc Medicare	$182.70
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$237.51

GRAFT HEMASHIELD VASCULAR

Facility

$350.00

Service Code	HCPCS C1768
Hospital Charge Code	40209392
Hospital Revenue Code	278
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$175.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$175.00
Rate for Payer: Hamaspik Choice Inc Medicare	$175.00

GRAFT HEMASHIELD VASCULAR

Facility

$2,184.00

Service Code	HCPCS C1768
Hospital Charge Code	64901154
Hospital Revenue Code	278
Min. Negotiated Rate	$1,092.00
Max. Negotiated Rate	$1,092.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,092.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,092.00

GRAFT HEMASHIELD VASCULAR

Facility

$350.00

Service Code	HCPCS C1768
Hospital Charge Code	40209392
Hospital Revenue Code	278
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$367.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$192.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Brighton Health Commercial	$210.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$175.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$201.25
Rate for Payer: EmblemHealth Commercial	$175.00
Rate for Payer: Fidelis Medicare Advantage	$367.50
Rate for Payer: Group Health Inc Commercial	$175.00
Rate for Payer: Group Health Inc Medicare	$122.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$175.00
Rate for Payer: Hamaspik Choice Inc Medicare	$175.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$227.50

GRAFT HEMASHIELD VASCULAR

Facility

$2,184.00

Service Code	HCPCS C1768
Hospital Charge Code	64901154
Hospital Revenue Code	278
Min. Negotiated Rate	$322.77
Max. Negotiated Rate	$2,293.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,201.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$322.77
Rate for Payer: Aetna Government	$322.77
Rate for Payer: Brighton Health Commercial	$1,310.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,092.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,255.80
Rate for Payer: EmblemHealth Commercial	$1,092.00
Rate for Payer: Fidelis Medicare Advantage	$2,293.20
Rate for Payer: Group Health Inc Commercial	$1,092.00
Rate for Payer: Group Health Inc Medicare	$764.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,092.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,092.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,419.60

Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate

Facility

$4,231.79

Service Code	CPT 15771
Hospital Revenue Code	360
Min. Negotiated Rate	$1,505.00
Max. Negotiated Rate	$4,231.79
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,485.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4,148.81
Rate for Payer: Aetna Government	$4,148.81
Rate for Payer: Affinity Essential Plan 1&2	$2,904.17
Rate for Payer: Affinity Essential Plan 3&4	$2,904.17
Rate for Payer: Affinity Medicaid/CHP/HARP	$2,904.17
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$4,148.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Elderplan Medicare Advantage	$4,148.81
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: Fidelis Essential Plan Aliesa	$3,526.49
Rate for Payer: Fidelis Essential Plan QHP	$3,692.44
Rate for Payer: Fidelis Medicare Advantage	$4,148.81
Rate for Payer: Fidelis Qualified Health Plan	$3,692.44
Rate for Payer: Group Health Inc Commercial	$4,148.81
Rate for Payer: Group Health Inc Medicare	$4,148.81
Rate for Payer: Hamaspik Choice Inc Medicare	$4,148.81
Rate for Payer: Healthfirst Medicare Advantage	$3,526.49
Rate for Payer: Healthfirst QHP	$4,148.81
Rate for Payer: Humana Medicare	$4,231.79
Rate for Payer: Senior Whole Health Medicare Advantage	$4,148.81
Rate for Payer: United Healthcare Commercial	$1,835.00
Rate for Payer: United Healthcare Medicare Advantage	$4,148.81
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,148.81
Rate for Payer: Wellcare CHP/FHP/Medicaid	$3,319.05
Rate for Payer: Wellcare Medicare	$3,941.37

Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure)

Facility

$2,915.00

Service Code	CPT 15772
Hospital Revenue Code	360
Min. Negotiated Rate	$125.85
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,485.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$125.85
Rate for Payer: Aetna Government	$125.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: EmblemHealth Commercial	$1,505.00
Rate for Payer: United Healthcare Commercial	$1,113.00

GRAFT INJECT PRO-DENSE 12CC

Facility

$15,317.50

Service Code	HCPCS C1763
Hospital Charge Code	64907463
Hospital Revenue Code	278
Min. Negotiated Rate	$320.50
Max. Negotiated Rate	$16,083.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8,424.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$320.50
Rate for Payer: Aetna Government	$320.50
Rate for Payer: Brighton Health Commercial	$9,190.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7,658.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$8,807.56
Rate for Payer: EmblemHealth Commercial	$7,658.75
Rate for Payer: Fidelis Medicare Advantage	$16,083.38
Rate for Payer: Group Health Inc Commercial	$7,658.75
Rate for Payer: Group Health Inc Medicare	$5,361.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$7,658.75
Rate for Payer: Hamaspik Choice Inc Medicare	$7,658.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9,956.38

GRAFT INJECT PRO-DENSE 12CC

Facility

$15,317.50

Service Code	HCPCS C1763
Hospital Charge Code	64907463
Hospital Revenue Code	278
Min. Negotiated Rate	$7,658.75
Max. Negotiated Rate	$7,658.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$7,658.75
Rate for Payer: Hamaspik Choice Inc Medicare	$7,658.75

GRAFT INJECT PRO-DENSE 15CC

Facility

$18,080.00

Service Code	HCPCS C1763
Hospital Charge Code	64907460
Hospital Revenue Code	278
Min. Negotiated Rate	$9,040.00
Max. Negotiated Rate	$9,040.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$9,040.00
Rate for Payer: Hamaspik Choice Inc Medicare	$9,040.00

GRAFT INJECT PRO-DENSE 15CC

Facility

$18,080.00

Service Code	HCPCS C1763
Hospital Charge Code	64907460
Hospital Revenue Code	278
Min. Negotiated Rate	$320.50
Max. Negotiated Rate	$18,984.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9,944.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$320.50
Rate for Payer: Aetna Government	$320.50
Rate for Payer: Brighton Health Commercial	$10,848.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9,040.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$10,396.00
Rate for Payer: EmblemHealth Commercial	$9,040.00
Rate for Payer: Fidelis Medicare Advantage	$18,984.00
Rate for Payer: Group Health Inc Commercial	$9,040.00
Rate for Payer: Group Health Inc Medicare	$6,328.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$9,040.00
Rate for Payer: Hamaspik Choice Inc Medicare	$9,040.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11,752.00

GRAFTJACKET, PER SQ CM

Facility

$184.64

Service Code	HCPCS Q4107
Hospital Charge Code	42500217
Hospital Revenue Code	636
Min. Negotiated Rate	$64.62
Max. Negotiated Rate	$120.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$101.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$69.78
Rate for Payer: Aetna Government	$69.78
Rate for Payer: Brighton Health Commercial	$110.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$92.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$106.17
Rate for Payer: Group Health Inc Commercial	$92.32
Rate for Payer: Group Health Inc Medicare	$64.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$92.32
Rate for Payer: Hamaspik Choice Inc Medicare	$92.32
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$120.02

GRAFTJACKET, PER SQ CM

Facility

$184.64

Service Code	HCPCS Q4107
Hospital Charge Code	42500217
Hospital Revenue Code	636
Min. Negotiated Rate	$92.32
Max. Negotiated Rate	$92.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$92.32
Rate for Payer: Hamaspik Choice Inc Medicare	$92.32

GRAFT NERVE

Facility

$7,087.50

Hospital Charge Code	64907146
Hospital Revenue Code	279
Min. Negotiated Rate	$2,480.62
Max. Negotiated Rate	$5,670.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,898.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,543.75
Rate for Payer: Aetna Government	$3,543.75
Rate for Payer: Brighton Health Commercial	$5,315.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5,670.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,819.50
Rate for Payer: Group Health Inc Commercial	$3,543.75
Rate for Payer: Group Health Inc Medicare	$2,480.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,543.75
Rate for Payer: Hamaspik Choice Inc Medicare	$3,543.75

GRAFT NERVE 1-12X30MM

Facility

$7,370.00

Hospital Charge Code	64907441
Hospital Revenue Code	279
Min. Negotiated Rate	$2,579.50
Max. Negotiated Rate	$5,896.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,053.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,685.00
Rate for Payer: Aetna Government	$3,685.00
Rate for Payer: Brighton Health Commercial	$5,527.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5,896.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$5,011.60
Rate for Payer: Group Health Inc Commercial	$3,685.00
Rate for Payer: Group Health Inc Medicare	$2,579.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,685.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,685.00

GRAFTON 1.5CMX1.5CM

Facility

$760.00

Service Code	HCPCS C1713
Hospital Charge Code	40202023
Hospital Revenue Code	278
Min. Negotiated Rate	$380.00
Max. Negotiated Rate	$380.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$380.00
Rate for Payer: Hamaspik Choice Inc Medicare	$380.00

GRAFTON 1.5CMX1.5CM

Facility

$760.00

Service Code	HCPCS C1713
Hospital Charge Code	40202023
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$798.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$418.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$456.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$380.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$437.00
Rate for Payer: EmblemHealth Commercial	$380.00
Rate for Payer: Fidelis Medicare Advantage	$798.00
Rate for Payer: Group Health Inc Commercial	$380.00
Rate for Payer: Group Health Inc Medicare	$266.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$380.00
Rate for Payer: Hamaspik Choice Inc Medicare	$380.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$494.00

GRAFTON 2.5CMX5CM

Facility

$1,630.00

Service Code	HCPCS C1713
Hospital Charge Code	40202024
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$1,711.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$896.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$978.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$815.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$937.25
Rate for Payer: EmblemHealth Commercial	$815.00
Rate for Payer: Fidelis Medicare Advantage	$1,711.50
Rate for Payer: Group Health Inc Commercial	$815.00
Rate for Payer: Group Health Inc Medicare	$570.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$815.00
Rate for Payer: Hamaspik Choice Inc Medicare	$815.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,059.50

GRAFTON 2.5CMX5CM

Facility

$1,630.00

Service Code	HCPCS C1713
Hospital Charge Code	40202024
Hospital Revenue Code	278
Min. Negotiated Rate	$815.00
Max. Negotiated Rate	$815.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$815.00
Rate for Payer: Hamaspik Choice Inc Medicare	$815.00

GRAFTON GEL 1CC

Facility

$416.00

Service Code	HCPCS C1713
Hospital Charge Code	40209644
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$436.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$228.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$249.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$208.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$239.20
Rate for Payer: EmblemHealth Commercial	$208.00
Rate for Payer: Fidelis Medicare Advantage	$436.80
Rate for Payer: Group Health Inc Commercial	$208.00
Rate for Payer: Group Health Inc Medicare	$145.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$208.00
Rate for Payer: Hamaspik Choice Inc Medicare	$208.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$270.40

GRAFTON GEL 1CC

Facility

$400.00

Service Code	HCPCS C1713
Hospital Charge Code	40202025
Hospital Revenue Code	278
Min. Negotiated Rate	$200.00
Max. Negotiated Rate	$200.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$200.00
Rate for Payer: Hamaspik Choice Inc Medicare	$200.00

GRAFTON GEL 1CC

Facility

$416.00

Service Code	HCPCS C1713
Hospital Charge Code	40209644
Hospital Revenue Code	278
Min. Negotiated Rate	$208.00
Max. Negotiated Rate	$208.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$208.00
Rate for Payer: Hamaspik Choice Inc Medicare	$208.00

Know your out-of-pocket cost for care.

All Charges