St. Barnabas Hospital

All Charges

Charge

Type

Price

4H ST PLATE LONG,MAND,LOCK

Facility OP

$271.00

Service Code	HCPCS C1713
Hospital Charge Code	40209411
Hospital Revenue Code	278
Min. Negotiated Rate	$94.85
Max. Negotiated Rate	$284.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$149.05
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	$135.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$155.82
Rate for Payer: Fidelis Medicare Advantage	$284.55
Rate for Payer: Group Health Inc Commercial	$135.50
Rate for Payer: Group Health Inc Medicare	$94.85
Rate for Payer: Hamaspik Choice Inc Medicaid	$135.50
Rate for Payer: Hamaspik Choice Inc Medicare	$135.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$176.15

4H ST PLATE LONG,MAND,LOCK

Facility IP

$271.00

Service Code	HCPCS C1713
Hospital Charge Code	40209411
Hospital Revenue Code	278
Min. Negotiated Rate	$135.50
Max. Negotiated Rate	$135.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$135.50
Rate for Payer: Hamaspik Choice Inc Medicare	$135.50

.4MM 100X100 MESH MALLEABLE

Facility IP

$4,458.00

Service Code	HCPCS C1781
Hospital Charge Code	40205294
Hospital Revenue Code	278
Min. Negotiated Rate	$2,229.00
Max. Negotiated Rate	$2,229.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,229.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,229.00

.4MM 100X100 MESH MALLEABLE

Facility OP

$4,458.00

Service Code	HCPCS C1781
Hospital Charge Code	40205294
Hospital Revenue Code	278
Min. Negotiated Rate	$69.35
Max. Negotiated Rate	$4,680.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,451.90
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	$2,229.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,563.35
Rate for Payer: Fidelis Medicare Advantage	$4,680.90
Rate for Payer: Group Health Inc Commercial	$2,229.00
Rate for Payer: Group Health Inc Medicare	$1,560.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,229.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,229.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,897.70

.4MM EMERGENCY SCREW

Facility IP

$162.00

Service Code	HCPCS C1713
Hospital Charge Code	40205299
Hospital Revenue Code	278
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$81.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$81.00
Rate for Payer: Hamaspik Choice Inc Medicare	$81.00

.4MM EMERGENCY SCREW

Facility OP

$162.00

Service Code	HCPCS C1713
Hospital Charge Code	40205299
Hospital Revenue Code	278
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$170.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$89.10
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	$81.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$93.15
Rate for Payer: Fidelis Medicare Advantage	$170.10
Rate for Payer: Group Health Inc Commercial	$81.00
Rate for Payer: Group Health Inc Medicare	$56.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$81.00
Rate for Payer: Hamaspik Choice Inc Medicare	$81.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$105.30

4-NO PRIVATE

Facility IP

$4,209.70

Hospital Charge Code	30000027
Hospital Revenue Code	126
Min. Negotiated Rate	$933.00
Max. Negotiated Rate	$1,043.00
Rate for Payer: Carelon Behavioral Health CHP/Medicaid	$933.00
Rate for Payer: Optum Commercial/Medicare	$1,043.00
Rate for Payer: Optum Medicaid	$1,043.00

4 SINGLE STINGING INSECT VENOMS

Facility OP

$183.15

Service Code	HCPCS 95148
Hospital Charge Code	30304067
Hospital Revenue Code	510
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$100.73
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$81.46
Rate for Payer: Aetna Government	$81.46
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cash Price	$81.46
Rate for Payer: Cash Price	$81.46
Rate for Payer: Cash Price	$81.46
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$81.46
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Elderplan Medicare Advantage	$81.46
Rate for Payer: Fidelis CHP/HARP/Medicaid	$3.38
Rate for Payer: Fidelis Essential Plan Aliesa	$69.24
Rate for Payer: Fidelis Essential Plan QHP	$72.50
Rate for Payer: Fidelis Medicare Advantage	$81.46
Rate for Payer: Fidelis Qualified Health Plan	$72.50
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$91.58
Rate for Payer: Hamaspik Choice Inc Medicare	$81.46
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$3.75
Rate for Payer: Healthfirst Medicare Advantage	$69.24
Rate for Payer: Healthfirst QHP	$81.46
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$81.46
Rate for Payer: Senior Whole Health Medicare Advantage	$81.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$81.46
Rate for Payer: Wellcare CHP/FHP/Medicaid	$65.17
Rate for Payer: Wellcare Medicare	$77.39

4-SO PRIVATE

Facility IP

$4,209.70

Hospital Charge Code	30000025
Hospital Revenue Code	126
Min. Negotiated Rate	$933.00
Max. Negotiated Rate	$1,043.00
Rate for Payer: Carelon Behavioral Health CHP/Medicaid	$933.00
Rate for Payer: Optum Commercial/Medicare	$1,043.00
Rate for Payer: Optum Medicaid	$1,043.00

4-TYPE SOL SET PRESS. PUMP

Facility OP

$9.57

Hospital Charge Code	40509819
Hospital Revenue Code	260
Min. Negotiated Rate	$3.35
Max. Negotiated Rate	$7.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.78
Rate for Payer: Aetna Government	$4.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.51
Rate for Payer: Group Health Inc Commercial	$4.78
Rate for Payer: Group Health Inc Medicare	$3.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.78
Rate for Payer: Hamaspik Choice Inc Medicare	$4.78

4-TYPE TUR ADM. SET

Facility OP

$15.95

Hospital Charge Code	40509821
Hospital Revenue Code	260
Min. Negotiated Rate	$5.58
Max. Negotiated Rate	$12.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.77
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.98
Rate for Payer: Aetna Government	$7.98
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.85
Rate for Payer: Group Health Inc Commercial	$7.98
Rate for Payer: Group Health Inc Medicare	$5.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.98
Rate for Payer: Hamaspik Choice Inc Medicare	$7.98

4x5 Bioclusive Dressing

Facility OP

$6.73

Hospital Charge Code	40200006
Hospital Revenue Code	270
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$5.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.36
Rate for Payer: Aetna Government	$3.36
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.58
Rate for Payer: Group Health Inc Commercial	$3.36
Rate for Payer: Group Health Inc Medicare	$2.36
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.36
Rate for Payer: Hamaspik Choice Inc Medicare	$3.36

500CC TISSUE EXPANDER

Facility IP

$2,700.00

Service Code	HCPCS C1789
Hospital Charge Code	40009271
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

500CC TISSUE EXPANDER

Facility OP

$2,700.00

Service Code	HCPCS C1789
Hospital Charge Code	40009271
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

500CC TISSUE EXPANDER 133MX-13-T

Facility OP

$3,375.00

Service Code	HCPCS C1789
Hospital Charge Code	40005326
Hospital Revenue Code	278
Min. Negotiated Rate	$402.32
Max. Negotiated Rate	$3,543.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,856.25
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	$1,687.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,940.62
Rate for Payer: Fidelis Medicare Advantage	$3,543.75
Rate for Payer: Group Health Inc Commercial	$1,687.50
Rate for Payer: Group Health Inc Medicare	$1,181.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,687.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,687.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,193.75

500CC TISSUE EXPANDER 133MX-13-T

Facility IP

$3,375.00

Service Code	HCPCS C1789
Hospital Charge Code	40005326
Hospital Revenue Code	278
Min. Negotiated Rate	$1,687.50
Max. Negotiated Rate	$1,687.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,687.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,687.50

5.0MMX30MM MOTIONLOC SCREW TI

Facility IP

$400.48

Service Code	HCPCS C1713
Hospital Charge Code	40007223
Hospital Revenue Code	278
Min. Negotiated Rate	$200.24
Max. Negotiated Rate	$200.24
Rate for Payer: Hamaspik Choice Inc Medicaid	$200.24
Rate for Payer: Hamaspik Choice Inc Medicare	$200.24

5.0MMX30MM MOTIONLOC SCREW TI

Facility OP

$400.48

Service Code	HCPCS C1713
Hospital Charge Code	40007223
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$420.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$220.26
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	$200.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$230.28
Rate for Payer: Fidelis Medicare Advantage	$420.50
Rate for Payer: Group Health Inc Commercial	$200.24
Rate for Payer: Group Health Inc Medicare	$140.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$200.24
Rate for Payer: Hamaspik Choice Inc Medicare	$200.24
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$260.31

5.0MMX30MM MOTIONLOC SCR TI STRL

Facility IP

$400.48

Service Code	HCPCS C1713
Hospital Charge Code	40006959
Hospital Revenue Code	278
Min. Negotiated Rate	$200.24
Max. Negotiated Rate	$200.24
Rate for Payer: Hamaspik Choice Inc Medicaid	$200.24
Rate for Payer: Hamaspik Choice Inc Medicare	$200.24

5.0MMX30MM MOTIONLOC SCR TI STRL

Facility OP

$400.48

Service Code	HCPCS C1713
Hospital Charge Code	40006959
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$420.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$220.26
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	$200.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$230.28
Rate for Payer: Fidelis Medicare Advantage	$420.50
Rate for Payer: Group Health Inc Commercial	$200.24
Rate for Payer: Group Health Inc Medicare	$140.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$200.24
Rate for Payer: Hamaspik Choice Inc Medicare	$200.24
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$260.31

5.0MMX32MM MOTIONLOC SCREW TI

Facility IP

$400.48

Service Code	HCPCS C1713
Hospital Charge Code	40007224
Hospital Revenue Code	278
Min. Negotiated Rate	$200.24
Max. Negotiated Rate	$200.24
Rate for Payer: Hamaspik Choice Inc Medicaid	$200.24
Rate for Payer: Hamaspik Choice Inc Medicare	$200.24

5.0MMX32MM MOTIONLOC SCREW TI

Facility OP

$400.48

Service Code	HCPCS C1713
Hospital Charge Code	40007224
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$420.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$220.26
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	$200.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$230.28
Rate for Payer: Fidelis Medicare Advantage	$420.50
Rate for Payer: Group Health Inc Commercial	$200.24
Rate for Payer: Group Health Inc Medicare	$140.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$200.24
Rate for Payer: Hamaspik Choice Inc Medicare	$200.24
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$260.31

5.0MMX34MM MOTIONLOC SCREW TI

Facility IP

$400.48

Service Code	HCPCS C1713
Hospital Charge Code	40007225
Hospital Revenue Code	278
Min. Negotiated Rate	$200.24
Max. Negotiated Rate	$200.24
Rate for Payer: Hamaspik Choice Inc Medicaid	$200.24
Rate for Payer: Hamaspik Choice Inc Medicare	$200.24

5.0MMX34MM MOTIONLOC SCREW TI

Facility OP

$400.48

Service Code	HCPCS C1713
Hospital Charge Code	40007225
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$420.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$220.26
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	$200.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$230.28
Rate for Payer: Fidelis Medicare Advantage	$420.50
Rate for Payer: Group Health Inc Commercial	$200.24
Rate for Payer: Group Health Inc Medicare	$140.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$200.24
Rate for Payer: Hamaspik Choice Inc Medicare	$200.24
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$260.31

5.0MMX34MM MOTIONLOC SCR TI STRL

Facility OP

$400.48

Service Code	HCPCS C1713
Hospital Charge Code	40006961
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$420.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$220.26
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	$200.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$230.28
Rate for Payer: Fidelis Medicare Advantage	$420.50
Rate for Payer: Group Health Inc Commercial	$200.24
Rate for Payer: Group Health Inc Medicare	$140.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$200.24
Rate for Payer: Hamaspik Choice Inc Medicare	$200.24
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$260.31

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