St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PLATE 2.0MM 6H

Facility

$191.00

Service Code	HCPCS C1713
Hospital Charge Code	40200718
Hospital Revenue Code	278
Min. Negotiated Rate	$66.85
Max. Negotiated Rate	$200.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$105.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$114.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$95.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$109.82
Rate for Payer: EmblemHealth Commercial	$95.50
Rate for Payer: Fidelis Medicare Advantage	$200.55
Rate for Payer: Group Health Inc Commercial	$95.50
Rate for Payer: Group Health Inc Medicare	$66.85
Rate for Payer: Hamaspik Choice Inc Medicaid	$95.50
Rate for Payer: Hamaspik Choice Inc Medicare	$95.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$124.15

PLATE 2.0MM 6H

Facility

$191.00

Service Code	HCPCS C1713
Hospital Charge Code	40200718
Hospital Revenue Code	278
Min. Negotiated Rate	$95.50
Max. Negotiated Rate	$95.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$95.50
Rate for Payer: Hamaspik Choice Inc Medicare	$95.50

PLATE 24HOLE STRT UPPERFACE

Facility

$927.53

Service Code	HCPCS C1713
Hospital Charge Code	64901534
Hospital Revenue Code	278
Min. Negotiated Rate	$463.76
Max. Negotiated Rate	$463.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$463.76
Rate for Payer: Hamaspik Choice Inc Medicare	$463.76

PLATE 24HOLE STRT UPPERFACE

Facility

$927.53

Service Code	HCPCS C1713
Hospital Charge Code	64901534
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$973.91
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$510.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$556.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$463.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$533.33
Rate for Payer: EmblemHealth Commercial	$463.76
Rate for Payer: Fidelis Medicare Advantage	$973.91
Rate for Payer: Group Health Inc Commercial	$463.76
Rate for Payer: Group Health Inc Medicare	$324.64
Rate for Payer: Hamaspik Choice Inc Medicaid	$463.76
Rate for Payer: Hamaspik Choice Inc Medicare	$463.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$602.89

PLATE 24H STRT MDFC MLBL CNDS

Facility

$1,093.13

Service Code	HCPCS C1713
Hospital Charge Code	64901557
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$1,147.79
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$601.22
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$655.88
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$546.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$628.55
Rate for Payer: EmblemHealth Commercial	$546.56
Rate for Payer: Fidelis Medicare Advantage	$1,147.79
Rate for Payer: Group Health Inc Commercial	$546.56
Rate for Payer: Group Health Inc Medicare	$382.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$546.56
Rate for Payer: Hamaspik Choice Inc Medicare	$546.56
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$710.53

PLATE 24H STRT MDFC MLBL CNDS

Facility

$1,093.13

Service Code	HCPCS C1713
Hospital Charge Code	64901557
Hospital Revenue Code	278
Min. Negotiated Rate	$546.56
Max. Negotiated Rate	$546.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$546.56
Rate for Payer: Hamaspik Choice Inc Medicare	$546.56

PLATE 24H STRT UP MALL CNDSD-4424

Facility

$436.59

Service Code	HCPCS C1713
Hospital Charge Code	64906521
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$458.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$240.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$261.95
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$218.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$251.04
Rate for Payer: EmblemHealth Commercial	$218.30
Rate for Payer: Fidelis Medicare Advantage	$458.42
Rate for Payer: Group Health Inc Commercial	$218.30
Rate for Payer: Group Health Inc Medicare	$152.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$218.30
Rate for Payer: Hamaspik Choice Inc Medicare	$218.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$283.78

PLATE 24H STRT UP MALL CNDSD-4424

Facility

$436.59

Service Code	HCPCS C1713
Hospital Charge Code	64906521
Hospital Revenue Code	278
Min. Negotiated Rate	$218.30
Max. Negotiated Rate	$218.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$218.30
Rate for Payer: Hamaspik Choice Inc Medicare	$218.30

PLATE 2.4 LCPT

Facility

$2,475.00

Service Code	HCPCS C1713
Hospital Charge Code	64903026
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,598.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,361.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$1,485.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,237.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,423.12
Rate for Payer: EmblemHealth Commercial	$1,237.50
Rate for Payer: Fidelis Medicare Advantage	$2,598.75
Rate for Payer: Group Health Inc Commercial	$1,237.50
Rate for Payer: Group Health Inc Medicare	$866.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,237.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,237.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,608.75

PLATE 2.4 LCPT

Facility

$2,475.00

Service Code	HCPCS C1713
Hospital Charge Code	64903026
Hospital Revenue Code	278
Min. Negotiated Rate	$1,237.50
Max. Negotiated Rate	$1,237.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,237.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,237.50

PLATE 2.4MM PRIMARY RECON

Facility

$5,558.40

Service Code	HCPCS C1713
Hospital Charge Code	64903163
Hospital Revenue Code	278
Min. Negotiated Rate	$2,779.20
Max. Negotiated Rate	$2,779.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,779.20
Rate for Payer: Hamaspik Choice Inc Medicare	$2,779.20

PLATE 2.4MM PRIMARY RECON

Facility

$5,558.40

Service Code	HCPCS C1713
Hospital Charge Code	64903163
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$5,836.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,057.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$3,335.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,779.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,196.08
Rate for Payer: EmblemHealth Commercial	$2,779.20
Rate for Payer: Fidelis Medicare Advantage	$5,836.32
Rate for Payer: Group Health Inc Commercial	$2,779.20
Rate for Payer: Group Health Inc Medicare	$1,945.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,779.20
Rate for Payer: Hamaspik Choice Inc Medicare	$2,779.20
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,612.96

PLATE 26MM TRINICA SELECT

Facility

$4,940.00

Service Code	HCPCS C1713
Hospital Charge Code	64904367
Hospital Revenue Code	278
Min. Negotiated Rate	$2,470.00
Max. Negotiated Rate	$2,470.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,470.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,470.00

PLATE 26MM TRINICA SELECT

Facility

$4,940.00

Service Code	HCPCS C1713
Hospital Charge Code	64904367
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$5,187.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,717.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$2,964.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,470.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,840.50
Rate for Payer: EmblemHealth Commercial	$2,470.00
Rate for Payer: Fidelis Medicare Advantage	$5,187.00
Rate for Payer: Group Health Inc Commercial	$2,470.00
Rate for Payer: Group Health Inc Medicare	$1,729.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,470.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,470.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,211.00

PLATE, 2 HOLE W TAB

Facility

$271.33

Service Code	HCPCS C1713
Hospital Charge Code	64904392
Hospital Revenue Code	278
Min. Negotiated Rate	$135.66
Max. Negotiated Rate	$135.66
Rate for Payer: Hamaspik Choice Inc Medicaid	$135.66
Rate for Payer: Hamaspik Choice Inc Medicare	$135.66

PLATE, 2 HOLE W TAB

Facility

$271.33

Service Code	HCPCS C1713
Hospital Charge Code	64904392
Hospital Revenue Code	278
Min. Negotiated Rate	$94.97
Max. Negotiated Rate	$284.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$149.23
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$162.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$135.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$156.01
Rate for Payer: EmblemHealth Commercial	$135.66
Rate for Payer: Fidelis Medicare Advantage	$284.90
Rate for Payer: Group Health Inc Commercial	$135.66
Rate for Payer: Group Health Inc Medicare	$94.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$135.66
Rate for Payer: Hamaspik Choice Inc Medicare	$135.66
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$176.36

PLATE 2 LEV 40MM

Facility

$4,389.38

Service Code	HCPCS C1889
Hospital Charge Code	64907495
Hospital Revenue Code	278
Min. Negotiated Rate	$1,536.28
Max. Negotiated Rate	$4,608.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,414.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2,194.69
Rate for Payer: Aetna Government	$2,194.69
Rate for Payer: Brighton Health Commercial	$2,633.63
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,194.69
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,523.89
Rate for Payer: EmblemHealth Commercial	$2,194.69
Rate for Payer: Fidelis Medicare Advantage	$4,608.85
Rate for Payer: Group Health Inc Commercial	$2,194.69
Rate for Payer: Group Health Inc Medicare	$1,536.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,194.69
Rate for Payer: Hamaspik Choice Inc Medicare	$2,194.69
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,853.10

PLATE 2 LEV 40MM

Facility

$4,389.38

Service Code	HCPCS C1889
Hospital Charge Code	64907495
Hospital Revenue Code	278
Min. Negotiated Rate	$2,194.69
Max. Negotiated Rate	$2,194.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,194.69
Rate for Payer: Hamaspik Choice Inc Medicare	$2,194.69

PLATE 2X2 HOLE 3D MDFACE LOCK

Facility

$535.20

Service Code	HCPCS C1713
Hospital Charge Code	64901582
Hospital Revenue Code	278
Min. Negotiated Rate	$267.60
Max. Negotiated Rate	$267.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$267.60
Rate for Payer: Hamaspik Choice Inc Medicare	$267.60

PLATE 2X2 HOLE 3D MDFACE LOCK

Facility

$535.20

Service Code	HCPCS C1713
Hospital Charge Code	64901582
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$561.96
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$294.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$321.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$267.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$307.74
Rate for Payer: EmblemHealth Commercial	$267.60
Rate for Payer: Fidelis Medicare Advantage	$561.96
Rate for Payer: Group Health Inc Commercial	$267.60
Rate for Payer: Group Health Inc Medicare	$187.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$267.60
Rate for Payer: Hamaspik Choice Inc Medicare	$267.60
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$347.88

PLATE 2X2 HOLE 3D MIDFACE

Facility

$465.08

Service Code	HCPCS C1713
Hospital Charge Code	64901565
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$488.33
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$255.79
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$279.05
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$232.54
Rate for Payer: Cigna LocalPlus Benefit Plan	$267.42
Rate for Payer: EmblemHealth Commercial	$232.54
Rate for Payer: Fidelis Medicare Advantage	$488.33
Rate for Payer: Group Health Inc Commercial	$232.54
Rate for Payer: Group Health Inc Medicare	$162.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$232.54
Rate for Payer: Hamaspik Choice Inc Medicare	$232.54
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$302.30

PLATE 2X2 HOLE 3D MIDFACE

Facility

$465.08

Service Code	HCPCS C1713
Hospital Charge Code	64901565
Hospital Revenue Code	278
Min. Negotiated Rate	$232.54
Max. Negotiated Rate	$232.54
Rate for Payer: Hamaspik Choice Inc Medicaid	$232.54
Rate for Payer: Hamaspik Choice Inc Medicare	$232.54

PLATE 2X2 HOLE 3D UPFACE MALLBL

Facility

$459.35

Service Code	HCPCS C1713
Hospital Charge Code	64901530
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$482.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$252.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$275.61
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$229.68
Rate for Payer: Cigna LocalPlus Benefit Plan	$264.13
Rate for Payer: EmblemHealth Commercial	$229.68
Rate for Payer: Fidelis Medicare Advantage	$482.32
Rate for Payer: Group Health Inc Commercial	$229.68
Rate for Payer: Group Health Inc Medicare	$160.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$229.68
Rate for Payer: Hamaspik Choice Inc Medicare	$229.68
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$298.58

PLATE 2X2 HOLE 3D UPFACE MALLBL

Facility

$459.35

Service Code	HCPCS C1713
Hospital Charge Code	64901530
Hospital Revenue Code	278
Min. Negotiated Rate	$229.68
Max. Negotiated Rate	$229.68
Rate for Payer: Hamaspik Choice Inc Medicaid	$229.68
Rate for Payer: Hamaspik Choice Inc Medicare	$229.68

PLATE 2X2 HOLE 3D UPPERFACE

Facility

$432.55

Service Code	HCPCS C1713
Hospital Charge Code	64901542
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$454.18
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$237.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$259.53
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$216.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$248.72
Rate for Payer: EmblemHealth Commercial	$216.28
Rate for Payer: Fidelis Medicare Advantage	$454.18
Rate for Payer: Group Health Inc Commercial	$216.28
Rate for Payer: Group Health Inc Medicare	$151.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$216.28
Rate for Payer: Hamaspik Choice Inc Medicare	$216.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$281.16

Know your out-of-pocket cost for care.

All Charges