St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PLATE 3D 3X2 HOLE RECTANGLE

Facility

$520.00

Service Code	HCPCS C1781
Hospital Charge Code	40209743
Hospital Revenue Code	278
Min. Negotiated Rate	$260.00
Max. Negotiated Rate	$260.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$260.00
Rate for Payer: Hamaspik Choice Inc Medicare	$260.00

PLATE 3D 3X2 HOLE RECTANGLE

Facility

$520.00

Service Code	HCPCS C1781
Hospital Charge Code	40209743
Hospital Revenue Code	278
Min. Negotiated Rate	$69.35
Max. Negotiated Rate	$546.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$286.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$69.35
Rate for Payer: Aetna Government	$69.35
Rate for Payer: Brighton Health Commercial	$312.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$260.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$299.00
Rate for Payer: EmblemHealth Commercial	$260.00
Rate for Payer: Fidelis Medicare Advantage	$546.00
Rate for Payer: Group Health Inc Commercial	$260.00
Rate for Payer: Group Health Inc Medicare	$182.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$260.00
Rate for Payer: Hamaspik Choice Inc Medicare	$260.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$338.00

PLATE 3D 4X2 HOLE SQUARE

Facility

$712.78

Service Code	HCPCS C1713
Hospital Charge Code	64901481
Hospital Revenue Code	278
Min. Negotiated Rate	$356.39
Max. Negotiated Rate	$356.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$356.39
Rate for Payer: Hamaspik Choice Inc Medicare	$356.39

PLATE 3D 4X2 HOLE SQUARE

Facility

$712.78

Service Code	HCPCS C1713
Hospital Charge Code	64901481
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$748.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$392.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$427.67
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$356.39
Rate for Payer: Cigna LocalPlus Benefit Plan	$409.85
Rate for Payer: EmblemHealth Commercial	$356.39
Rate for Payer: Fidelis Medicare Advantage	$748.42
Rate for Payer: Group Health Inc Commercial	$356.39
Rate for Payer: Group Health Inc Medicare	$249.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$356.39
Rate for Payer: Hamaspik Choice Inc Medicare	$356.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$463.31

PLATE 3D 5X2 1.5 PROFILE

Facility

$1,545.60

Service Code	HCPCS C1713
Hospital Charge Code	64904779
Hospital Revenue Code	278
Min. Negotiated Rate	$772.80
Max. Negotiated Rate	$772.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$772.80
Rate for Payer: Hamaspik Choice Inc Medicare	$772.80

PLATE 3D 5X2 1.5 PROFILE

Facility

$1,545.60

Service Code	HCPCS C1713
Hospital Charge Code	64904779
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$1,622.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$850.08
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$927.36
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$772.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$888.72
Rate for Payer: EmblemHealth Commercial	$772.80
Rate for Payer: Fidelis Medicare Advantage	$1,622.88
Rate for Payer: Group Health Inc Commercial	$772.80
Rate for Payer: Group Health Inc Medicare	$540.96
Rate for Payer: Hamaspik Choice Inc Medicaid	$772.80
Rate for Payer: Hamaspik Choice Inc Medicare	$772.80
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,004.64

PLATE 3-D 6X2 HOLE (55-03733)

Facility

$737.46

Service Code	HCPCS C1713
Hospital Charge Code	64906622
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$774.33
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$405.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$442.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$368.73
Rate for Payer: Cigna LocalPlus Benefit Plan	$424.04
Rate for Payer: EmblemHealth Commercial	$368.73
Rate for Payer: Fidelis Medicare Advantage	$774.33
Rate for Payer: Group Health Inc Commercial	$368.73
Rate for Payer: Group Health Inc Medicare	$258.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$368.73
Rate for Payer: Hamaspik Choice Inc Medicare	$368.73
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$479.35

PLATE 3-D 6X2 HOLE (55-03733)

Facility

$737.46

Service Code	HCPCS C1713
Hospital Charge Code	64906622
Hospital Revenue Code	278
Min. Negotiated Rate	$368.73
Max. Negotiated Rate	$368.73
Rate for Payer: Hamaspik Choice Inc Medicaid	$368.73
Rate for Payer: Hamaspik Choice Inc Medicare	$368.73

PLATE 3D 6X2 HOLE CURVED SQUARE

Facility

$842.68

Service Code	HCPCS C1713
Hospital Charge Code	64901483
Hospital Revenue Code	278
Min. Negotiated Rate	$421.34
Max. Negotiated Rate	$421.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$421.34
Rate for Payer: Hamaspik Choice Inc Medicare	$421.34

PLATE 3D 6X2 HOLE CURVED SQUARE

Facility

$842.68

Service Code	HCPCS C1713
Hospital Charge Code	64901483
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$884.81
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$463.47
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$505.61
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$421.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$484.54
Rate for Payer: EmblemHealth Commercial	$421.34
Rate for Payer: Fidelis Medicare Advantage	$884.81
Rate for Payer: Group Health Inc Commercial	$421.34
Rate for Payer: Group Health Inc Medicare	$294.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$421.34
Rate for Payer: Hamaspik Choice Inc Medicare	$421.34
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$547.74

PLATE 3-D 6X6 HOLE (55-04235)

Facility

$1,523.52

Service Code	HCPCS C1713
Hospital Charge Code	64906625
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$1,599.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$837.94
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$914.11
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$761.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$876.02
Rate for Payer: EmblemHealth Commercial	$761.76
Rate for Payer: Fidelis Medicare Advantage	$1,599.70
Rate for Payer: Group Health Inc Commercial	$761.76
Rate for Payer: Group Health Inc Medicare	$533.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$761.76
Rate for Payer: Hamaspik Choice Inc Medicare	$761.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$990.29

PLATE 3-D 6X6 HOLE (55-04235)

Facility

$1,523.52

Service Code	HCPCS C1713
Hospital Charge Code	64906625
Hospital Revenue Code	278
Min. Negotiated Rate	$761.76
Max. Negotiated Rate	$761.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$761.76
Rate for Payer: Hamaspik Choice Inc Medicare	$761.76

PLATE 3D FL PROFIL .6M 2X2L QUAD

Facility

$455.90

Service Code	HCPCS C1713
Hospital Charge Code	64902012
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$478.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$250.74
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$273.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$227.95
Rate for Payer: Cigna LocalPlus Benefit Plan	$262.14
Rate for Payer: EmblemHealth Commercial	$227.95
Rate for Payer: Fidelis Medicare Advantage	$478.70
Rate for Payer: Group Health Inc Commercial	$227.95
Rate for Payer: Group Health Inc Medicare	$159.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$227.95
Rate for Payer: Hamaspik Choice Inc Medicare	$227.95
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$296.34

PLATE 3D FL PROFIL .6M 2X2L QUAD

Facility

$455.90

Service Code	HCPCS C1713
Hospital Charge Code	64902012
Hospital Revenue Code	278
Min. Negotiated Rate	$227.95
Max. Negotiated Rate	$227.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$227.95
Rate for Payer: Hamaspik Choice Inc Medicare	$227.95

PLATE 42 MM TRINICA

Facility

$5,350.00

Service Code	HCPCS C1713
Hospital Charge Code	64904510
Hospital Revenue Code	278
Min. Negotiated Rate	$2,675.00
Max. Negotiated Rate	$2,675.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,675.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,675.00

PLATE 42 MM TRINICA

Facility

$5,350.00

Service Code	HCPCS C1713
Hospital Charge Code	64904510
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$5,617.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,942.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$3,210.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,675.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,076.25
Rate for Payer: EmblemHealth Commercial	$2,675.00
Rate for Payer: Fidelis Medicare Advantage	$5,617.50
Rate for Payer: Group Health Inc Commercial	$2,675.00
Rate for Payer: Group Health Inc Medicare	$1,872.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,675.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,675.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,477.50

PLATE 4H LEFT LCP

Facility

$1,796.00

Service Code	HCPCS C1713
Hospital Charge Code	40209896
Hospital Revenue Code	278
Min. Negotiated Rate	$898.00
Max. Negotiated Rate	$898.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$898.00
Rate for Payer: Hamaspik Choice Inc Medicare	$898.00

PLATE 4H LEFT LCP

Facility

$1,796.00

Service Code	HCPCS C1713
Hospital Charge Code	40209896
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$1,885.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$987.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$1,077.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$898.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,032.70
Rate for Payer: EmblemHealth Commercial	$898.00
Rate for Payer: Fidelis Medicare Advantage	$1,885.80
Rate for Payer: Group Health Inc Commercial	$898.00
Rate for Payer: Group Health Inc Medicare	$628.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$898.00
Rate for Payer: Hamaspik Choice Inc Medicare	$898.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,167.40

PLATE 4 HOLE

Facility

$679.06

Service Code	HCPCS C1713
Hospital Charge Code	40200719
Hospital Revenue Code	278
Min. Negotiated Rate	$339.53
Max. Negotiated Rate	$339.53
Rate for Payer: Hamaspik Choice Inc Medicaid	$339.53
Rate for Payer: Hamaspik Choice Inc Medicare	$339.53

PLATE 4 HOLE

Facility

$679.06

Service Code	HCPCS C1713
Hospital Charge Code	40200719
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$713.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$373.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$407.44
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$339.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$390.46
Rate for Payer: EmblemHealth Commercial	$339.53
Rate for Payer: Fidelis Medicare Advantage	$713.01
Rate for Payer: Group Health Inc Commercial	$339.53
Rate for Payer: Group Health Inc Medicare	$237.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$339.53
Rate for Payer: Hamaspik Choice Inc Medicare	$339.53
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$441.39

PLATE 4 HOLE

Facility

$1,131.00

Service Code	HCPCS C1713
Hospital Charge Code	64903530
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$1,187.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$622.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$678.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$565.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$650.32
Rate for Payer: EmblemHealth Commercial	$565.50
Rate for Payer: Fidelis Medicare Advantage	$1,187.55
Rate for Payer: Group Health Inc Commercial	$565.50
Rate for Payer: Group Health Inc Medicare	$395.85
Rate for Payer: Hamaspik Choice Inc Medicaid	$565.50
Rate for Payer: Hamaspik Choice Inc Medicare	$565.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$735.15

PLATE 4 HOLE

Facility

$1,131.00

Service Code	HCPCS C1713
Hospital Charge Code	64903530
Hospital Revenue Code	278
Min. Negotiated Rate	$565.50
Max. Negotiated Rate	$565.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$565.50
Rate for Payer: Hamaspik Choice Inc Medicare	$565.50

PLATE 4HOLE 1/3 TUBULAR (AR-892BT

Facility

$225.00

Service Code	HCPCS C1713
Hospital Charge Code	64906355
Hospital Revenue Code	278
Min. Negotiated Rate	$78.75
Max. Negotiated Rate	$236.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$123.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$135.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$112.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$129.38
Rate for Payer: EmblemHealth Commercial	$112.50
Rate for Payer: Fidelis Medicare Advantage	$236.25
Rate for Payer: Group Health Inc Commercial	$112.50
Rate for Payer: Group Health Inc Medicare	$78.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$112.50
Rate for Payer: Hamaspik Choice Inc Medicare	$112.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$146.25

PLATE 4HOLE 1/3 TUBULAR (AR-892BT

Facility

$225.00

Service Code	HCPCS C1713
Hospital Charge Code	64906355
Hospital Revenue Code	278
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$112.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$112.50
Rate for Payer: Hamaspik Choice Inc Medicare	$112.50

PLATE 4 HOLE (626964)

Facility

$2,782.00

Service Code	HCPCS C1713
Hospital Charge Code	64906676
Hospital Revenue Code	278
Min. Negotiated Rate	$1,391.00
Max. Negotiated Rate	$1,391.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,391.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,391.00

Know your out-of-pocket cost for care.

All Charges