St. Barnabas Hospital

All Charges

Charge

Type

Price

2X6H 3D PLT MIDFACE

Facility IP

$822.00

Service Code	HCPCS C1781
Hospital Charge Code	40209818
Hospital Revenue Code	278
Min. Negotiated Rate	$411.00
Max. Negotiated Rate	$411.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$411.00
Rate for Payer: Hamaspik Choice Inc Medicare	$411.00

2X6H 3D PLT MIDFACE

Facility OP

$822.00

Service Code	HCPCS C1781
Hospital Charge Code	40209818
Hospital Revenue Code	278
Min. Negotiated Rate	$69.35
Max. Negotiated Rate	$863.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$452.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$69.35
Rate for Payer: Aetna Government	$69.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$411.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$472.65
Rate for Payer: Fidelis Medicare Advantage	$863.10
Rate for Payer: Group Health Inc Commercial	$411.00
Rate for Payer: Group Health Inc Medicare	$287.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$411.00
Rate for Payer: Hamaspik Choice Inc Medicare	$411.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$534.30

300CC TISSUE EXPANDER

Facility OP

$2,700.00

Service Code	HCPCS C1789
Hospital Charge Code	40009272
Hospital Revenue Code	278
Min. Negotiated Rate	$402.32
Max. Negotiated Rate	$2,835.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,485.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$402.32
Rate for Payer: Aetna Government	$402.32
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,350.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,552.50
Rate for Payer: Fidelis Medicare Advantage	$2,835.00
Rate for Payer: Group Health Inc Commercial	$1,350.00
Rate for Payer: Group Health Inc Medicare	$945.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,350.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,350.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,755.00

300CC TISSUE EXPANDER

Facility IP

$2,700.00

Service Code	HCPCS C1789
Hospital Charge Code	40009272
Hospital Revenue Code	278
Min. Negotiated Rate	$1,350.00
Max. Negotiated Rate	$1,350.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,350.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,350.00

300CC TISSUE EXPANDER 133MX-11-T

Facility OP

$2,700.00

Service Code	HCPCS C1789
Hospital Charge Code	40005327
Hospital Revenue Code	278
Min. Negotiated Rate	$402.32
Max. Negotiated Rate	$2,835.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,485.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$402.32
Rate for Payer: Aetna Government	$402.32
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,350.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,552.50
Rate for Payer: Fidelis Medicare Advantage	$2,835.00
Rate for Payer: Group Health Inc Commercial	$1,350.00
Rate for Payer: Group Health Inc Medicare	$945.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,350.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,350.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,755.00

300CC TISSUE EXPANDER 133MX-11-T

Facility IP

$2,700.00

Service Code	HCPCS C1789
Hospital Charge Code	40005327
Hospital Revenue Code	278
Min. Negotiated Rate	$1,350.00
Max. Negotiated Rate	$1,350.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,350.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,350.00

30 HOLE STRGHT PLATE,75MM PROFILE

Facility OP

$1,182.00

Service Code	HCPCS C1713
Hospital Charge Code	40201062
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$1,241.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$650.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$591.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$679.65
Rate for Payer: Fidelis Medicare Advantage	$1,241.10
Rate for Payer: Group Health Inc Commercial	$591.00
Rate for Payer: Group Health Inc Medicare	$413.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$591.00
Rate for Payer: Hamaspik Choice Inc Medicare	$591.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$768.30

30 HOLE STRGHT PLATE,75MM PROFILE

Facility IP

$1,182.00

Service Code	HCPCS C1713
Hospital Charge Code	40201062
Hospital Revenue Code	278
Min. Negotiated Rate	$591.00
Max. Negotiated Rate	$591.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$591.00
Rate for Payer: Hamaspik Choice Inc Medicare	$591.00

3.0MM NCB DRLL 4.0MM NCB DP TD SC

Facility OP

$326.32

Hospital Charge Code	40006765
Hospital Revenue Code	272
Min. Negotiated Rate	$114.21
Max. Negotiated Rate	$261.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$179.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$163.16
Rate for Payer: Aetna Government	$163.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$261.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$221.90
Rate for Payer: Group Health Inc Commercial	$163.16
Rate for Payer: Group Health Inc Medicare	$114.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$163.16
Rate for Payer: Hamaspik Choice Inc Medicare	$163.16

3.0MM PIN BY 355MM STERIL

Facility OP

$27.36

Service Code	HCPCS C1713
Hospital Charge Code	40006467
Hospital Revenue Code	278
Min. Negotiated Rate	$9.58
Max. Negotiated Rate	$134.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$15.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$13.68
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.73
Rate for Payer: Fidelis Medicare Advantage	$28.73
Rate for Payer: Group Health Inc Commercial	$13.68
Rate for Payer: Group Health Inc Medicare	$9.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$13.68
Rate for Payer: Hamaspik Choice Inc Medicare	$13.68
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$17.78

3.0MM PIN BY 355MM STERIL

Facility IP

$27.36

Service Code	HCPCS C1713
Hospital Charge Code	40006467
Hospital Revenue Code	278
Min. Negotiated Rate	$13.68
Max. Negotiated Rate	$13.68
Rate for Payer: Hamaspik Choice Inc Medicaid	$13.68
Rate for Payer: Hamaspik Choice Inc Medicare	$13.68

3.0MM THREAD GUIDE PIN

Facility IP

$194.40

Service Code	HCPCS C1713
Hospital Charge Code	40006466
Hospital Revenue Code	278
Min. Negotiated Rate	$97.20
Max. Negotiated Rate	$97.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$97.20
Rate for Payer: Hamaspik Choice Inc Medicare	$97.20

3.0MM THREAD GUIDE PIN

Facility OP

$194.40

Service Code	HCPCS C1713
Hospital Charge Code	40006466
Hospital Revenue Code	278
Min. Negotiated Rate	$68.04
Max. Negotiated Rate	$204.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$106.92
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$97.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$111.78
Rate for Payer: Fidelis Medicare Advantage	$204.12
Rate for Payer: Group Health Inc Commercial	$97.20
Rate for Payer: Group Health Inc Medicare	$68.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$97.20
Rate for Payer: Hamaspik Choice Inc Medicare	$97.20
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$126.36

3.1 LONG DRILL

Facility OP

$824.00

Hospital Charge Code	40005310
Hospital Revenue Code	272
Min. Negotiated Rate	$288.40
Max. Negotiated Rate	$659.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$453.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$412.00
Rate for Payer: Aetna Government	$412.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$659.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$560.32
Rate for Payer: Group Health Inc Commercial	$412.00
Rate for Payer: Group Health Inc Medicare	$288.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$412.00
Rate for Payer: Hamaspik Choice Inc Medicare	$412.00

3.2MM CLAIBRATED DRILL BIT

Facility OP

$416.00

Hospital Charge Code	40203560
Hospital Revenue Code	272
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$332.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$228.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$208.00
Rate for Payer: Aetna Government	$208.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$332.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$282.88
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

3.2MM SHORT BIT

Facility OP

$406.00

Hospital Charge Code	40203561
Hospital Revenue Code	272
Min. Negotiated Rate	$142.10
Max. Negotiated Rate	$324.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$223.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$203.00
Rate for Payer: Aetna Government	$203.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$324.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$276.08
Rate for Payer: Group Health Inc Commercial	$203.00
Rate for Payer: Group Health Inc Medicare	$142.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$203.00
Rate for Payer: Hamaspik Choice Inc Medicare	$203.00

3.3MM DRILL BIT NCB PP TRGT DEVIC

Facility OP

$200.24

Hospital Charge Code	40006802
Hospital Revenue Code	272
Min. Negotiated Rate	$70.08
Max. Negotiated Rate	$160.19
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$110.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$100.12
Rate for Payer: Aetna Government	$100.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$160.19
Rate for Payer: Cigna LocalPlus Benefit Plan	$136.16
Rate for Payer: Group Health Inc Commercial	$100.12
Rate for Payer: Group Health Inc Medicare	$70.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$100.12
Rate for Payer: Hamaspik Choice Inc Medicare	$100.12

3.3MM FREE HAND DRILL 152.5MM

Facility IP

$187.20

Service Code	HCPCS C1713
Hospital Charge Code	40006473
Hospital Revenue Code	278
Min. Negotiated Rate	$93.60
Max. Negotiated Rate	$93.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$93.60
Rate for Payer: Hamaspik Choice Inc Medicare	$93.60

3.3MM FREE HAND DRILL 152.5MM

Facility OP

$187.20

Service Code	HCPCS C1713
Hospital Charge Code	40006473
Hospital Revenue Code	278
Min. Negotiated Rate	$65.52
Max. Negotiated Rate	$196.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$102.96
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$93.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$107.64
Rate for Payer: Fidelis Medicare Advantage	$196.56
Rate for Payer: Group Health Inc Commercial	$93.60
Rate for Payer: Group Health Inc Medicare	$65.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$93.60
Rate for Payer: Hamaspik Choice Inc Medicare	$93.60
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$121.68

3.3MM FREE HAND TARG DRILL

Facility OP

$410.40

Service Code	HCPCS C1713
Hospital Charge Code	40006471
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$430.92
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$225.72
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$205.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$235.98
Rate for Payer: Fidelis Medicare Advantage	$430.92
Rate for Payer: Group Health Inc Commercial	$205.20
Rate for Payer: Group Health Inc Medicare	$143.64
Rate for Payer: Hamaspik Choice Inc Medicaid	$205.20
Rate for Payer: Hamaspik Choice Inc Medicare	$205.20
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$266.76

3.3MM FREE HAND TARG DRILL

Facility IP

$410.40

Service Code	HCPCS C1713
Hospital Charge Code	40006471
Hospital Revenue Code	278
Min. Negotiated Rate	$205.20
Max. Negotiated Rate	$205.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$205.20
Rate for Payer: Hamaspik Choice Inc Medicare	$205.20

3/4SZ LID W/RETENTION PLT SLIVER

Facility OP

$228.44

Hospital Charge Code	40209548
Hospital Revenue Code	270
Min. Negotiated Rate	$79.95
Max. Negotiated Rate	$182.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$125.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$114.22
Rate for Payer: Aetna Government	$114.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$182.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$155.34
Rate for Payer: Group Health Inc Commercial	$114.22
Rate for Payer: Group Health Inc Medicare	$79.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$114.22
Rate for Payer: Hamaspik Choice Inc Medicare	$114.22

3.5 DRILL BIT

Facility OP

$165.60

Hospital Charge Code	40202760
Hospital Revenue Code	272
Min. Negotiated Rate	$57.96
Max. Negotiated Rate	$132.48
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$91.08
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$82.80
Rate for Payer: Aetna Government	$82.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$132.48
Rate for Payer: Cigna LocalPlus Benefit Plan	$112.61
Rate for Payer: Group Health Inc Commercial	$82.80
Rate for Payer: Group Health Inc Medicare	$57.96
Rate for Payer: Hamaspik Choice Inc Medicaid	$82.80
Rate for Payer: Hamaspik Choice Inc Medicare	$82.80

3.5MML HEX DRIVER AR/DIST SCRW

Facility IP

$672.00

Service Code	HCPCS C1713
Hospital Charge Code	40006151
Hospital Revenue Code	278
Min. Negotiated Rate	$336.00
Max. Negotiated Rate	$336.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$336.00
Rate for Payer: Hamaspik Choice Inc Medicare	$336.00

3.5MML HEX DRIVER AR/DIST SCRW

Facility OP

$672.00

Service Code	HCPCS C1713
Hospital Charge Code	40006151
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$705.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$369.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$336.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$386.40
Rate for Payer: Fidelis Medicare Advantage	$705.60
Rate for Payer: Group Health Inc Commercial	$336.00
Rate for Payer: Group Health Inc Medicare	$235.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$336.00
Rate for Payer: Hamaspik Choice Inc Medicare	$336.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$436.80

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