St. Barnabas Hospital

All Charges

Charge

Type

Price

TIBIAL BASE ROTAT SZ 5 CEM

Facility OP

$3,500.00

Service Code	HCPCS C1776
Hospital Charge Code	40005151
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$3,675.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,925.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,750.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,012.50
Rate for Payer: Fidelis Medicare Advantage	$3,675.00
Rate for Payer: Group Health Inc Commercial	$1,750.00
Rate for Payer: Group Health Inc Medicare	$1,225.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,750.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,750.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,275.00

TIBIAL BASE ROTAT SZ 5 CEM

Facility IP

$4,375.00

Service Code	HCPCS C1776
Hospital Charge Code	64905240
Hospital Revenue Code	278
Min. Negotiated Rate	$2,187.50
Max. Negotiated Rate	$2,187.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,187.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2,187.50

TIBIAL BASE ROTAT SZ 5 CEM

Facility OP

$4,375.00

Service Code	HCPCS C1776
Hospital Charge Code	64905240
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$4,593.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,406.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,187.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,515.62
Rate for Payer: Fidelis Medicare Advantage	$4,593.75
Rate for Payer: Group Health Inc Commercial	$2,187.50
Rate for Payer: Group Health Inc Medicare	$1,531.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,187.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2,187.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,843.75

TIBIAL BASE ROTAT SZ 5 CEM

Facility IP

$3,500.00

Service Code	HCPCS C1776
Hospital Charge Code	40005151
Hospital Revenue Code	278
Min. Negotiated Rate	$1,750.00
Max. Negotiated Rate	$1,750.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,750.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,750.00

TIBIAL BEARING 12MMX71/75MM

Facility IP

$3,015.00

Service Code	HCPCS C1776
Hospital Charge Code	64903853
Hospital Revenue Code	278
Min. Negotiated Rate	$1,507.50
Max. Negotiated Rate	$1,507.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,507.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,507.50

TIBIAL BEARING 12MMX71/75MM

Facility OP

$3,015.00

Service Code	HCPCS C1776
Hospital Charge Code	64903853
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$3,165.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,658.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,507.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,733.62
Rate for Payer: Fidelis Medicare Advantage	$3,165.75
Rate for Payer: Group Health Inc Commercial	$1,507.50
Rate for Payer: Group Health Inc Medicare	$1,055.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,507.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,507.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,959.75

TIBIAL BEARING INSERT 3X9MM

Facility OP

$6,040.00

Service Code	HCPCS C1776
Hospital Charge Code	40200358
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$6,342.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,322.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,020.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,473.00
Rate for Payer: Fidelis Medicare Advantage	$6,342.00
Rate for Payer: Group Health Inc Commercial	$3,020.00
Rate for Payer: Group Health Inc Medicare	$2,114.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,020.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,020.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,926.00

TIBIAL BEARING INSERT 3X9MM

Facility IP

$6,040.00

Service Code	HCPCS C1776
Hospital Charge Code	40200358
Hospital Revenue Code	278
Min. Negotiated Rate	$3,020.00
Max. Negotiated Rate	$3,020.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,020.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,020.00

TIBIAL INSERT ROTAT SZ5 6MM

Facility OP

$2,100.00

Service Code	HCPCS C1776
Hospital Charge Code	40005152
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$2,205.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,155.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,050.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,207.50
Rate for Payer: Fidelis Medicare Advantage	$2,205.00
Rate for Payer: Group Health Inc Commercial	$1,050.00
Rate for Payer: Group Health Inc Medicare	$735.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,050.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,050.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,365.00

TIBIAL INSERT ROTAT SZ5 6MM

Facility OP

$2,625.00

Service Code	HCPCS C1776
Hospital Charge Code	64905242
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$2,756.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,443.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,312.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,509.38
Rate for Payer: Fidelis Medicare Advantage	$2,756.25
Rate for Payer: Group Health Inc Commercial	$1,312.50
Rate for Payer: Group Health Inc Medicare	$918.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,312.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,312.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,706.25

TIBIAL INSERT ROTAT SZ5 6MM

Facility IP

$2,100.00

Service Code	HCPCS C1776
Hospital Charge Code	40005152
Hospital Revenue Code	278
Min. Negotiated Rate	$1,050.00
Max. Negotiated Rate	$1,050.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,050.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,050.00

TIBIAL INSERT ROTAT SZ5 6MM

Facility IP

$2,625.00

Service Code	HCPCS C1776
Hospital Charge Code	64905242
Hospital Revenue Code	278
Min. Negotiated Rate	$1,312.50
Max. Negotiated Rate	$1,312.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,312.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,312.50

TIBIAL NAIL, STANDARD

Facility OP

$2,683.00

Hospital Charge Code	40202155
Hospital Revenue Code	270
Min. Negotiated Rate	$939.05
Max. Negotiated Rate	$2,146.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,475.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,341.50
Rate for Payer: Aetna Government	$1,341.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,146.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,824.44
Rate for Payer: Group Health Inc Commercial	$1,341.50
Rate for Payer: Group Health Inc Medicare	$939.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,341.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1,341.50

TIBIAL SLEEVE

Facility OP

$1,738.12

Service Code	HCPCS C1776
Hospital Charge Code	64907305
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$1,825.03
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$955.97
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$869.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$999.42
Rate for Payer: Fidelis Medicare Advantage	$1,825.03
Rate for Payer: Group Health Inc Commercial	$869.06
Rate for Payer: Group Health Inc Medicare	$608.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$869.06
Rate for Payer: Hamaspik Choice Inc Medicare	$869.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,129.78

TIBIAL SLEEVE

Facility IP

$1,738.12

Service Code	HCPCS C1776
Hospital Charge Code	64907305
Hospital Revenue Code	278
Min. Negotiated Rate	$869.06
Max. Negotiated Rate	$869.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$869.06
Rate for Payer: Hamaspik Choice Inc Medicare	$869.06

TIBIA NCB-PT 3H, 13H, LEFT

Facility IP

$3,615.30

Service Code	HCPCS C1713
Hospital Charge Code	64905606
Hospital Revenue Code	278
Min. Negotiated Rate	$1,807.65
Max. Negotiated Rate	$1,807.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,807.65
Rate for Payer: Hamaspik Choice Inc Medicare	$1,807.65

TIBIA NCB-PT 3H, 13H, LEFT

Facility OP

$3,615.30

Service Code	HCPCS C1713
Hospital Charge Code	64905606
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$3,796.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,988.42
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	$1,807.65
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,078.80
Rate for Payer: Fidelis Medicare Advantage	$3,796.06
Rate for Payer: Group Health Inc Commercial	$1,807.65
Rate for Payer: Group Health Inc Medicare	$1,265.36
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,807.65
Rate for Payer: Hamaspik Choice Inc Medicare	$1,807.65
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,349.94

TIBIA PSN RV

Facility IP

$12,812.50

Service Code	HCPCS C1776
Hospital Charge Code	64907167
Hospital Revenue Code	278
Min. Negotiated Rate	$6,406.25
Max. Negotiated Rate	$6,406.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$6,406.25
Rate for Payer: Hamaspik Choice Inc Medicare	$6,406.25

TIBIA PSN RV

Facility OP

$12,812.50

Service Code	HCPCS C1776
Hospital Charge Code	64907167
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$13,453.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7,046.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6,406.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$7,367.19
Rate for Payer: Fidelis Medicare Advantage	$13,453.12
Rate for Payer: Group Health Inc Commercial	$6,406.25
Rate for Payer: Group Health Inc Medicare	$4,484.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$6,406.25
Rate for Payer: Hamaspik Choice Inc Medicare	$6,406.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8,328.12

TIBIA PSN STEMMED RT SZ F

Facility OP

$4,000.00

Service Code	HCPCS C1776
Hospital Charge Code	64906856
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$4,200.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,200.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,000.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,300.00
Rate for Payer: Fidelis Medicare Advantage	$4,200.00
Rate for Payer: Group Health Inc Commercial	$2,000.00
Rate for Payer: Group Health Inc Medicare	$1,400.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,000.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,000.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,600.00

TIBIA PSN STEMMED RT SZ F

Facility IP

$4,000.00

Service Code	HCPCS C1776
Hospital Charge Code	64906856
Hospital Revenue Code	278
Min. Negotiated Rate	$2,000.00
Max. Negotiated Rate	$2,000.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,000.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,000.00

TIBIA PSN STM 5 DEG SZ C L

Facility IP

$5,000.00

Service Code	HCPCS C1713
Hospital Charge Code	64905666
Hospital Revenue Code	278
Min. Negotiated Rate	$2,500.00
Max. Negotiated Rate	$2,500.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,500.00

TIBIA PSN STM 5 DEG SZ C L

Facility OP

$5,000.00

Service Code	HCPCS C1713
Hospital Charge Code	64905666
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$5,250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,750.00
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	$2,500.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,875.00
Rate for Payer: Fidelis Medicare Advantage	$5,250.00
Rate for Payer: Group Health Inc Commercial	$2,500.00
Rate for Payer: Group Health Inc Medicare	$1,750.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,500.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,500.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,250.00

TIBIA PSN STM 5 DEG SZ G L

Facility OP

$4,400.00

Service Code	HCPCS C1776
Hospital Charge Code	40204652
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$4,620.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,420.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,200.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,530.00
Rate for Payer: Fidelis Medicare Advantage	$4,620.00
Rate for Payer: Group Health Inc Commercial	$2,200.00
Rate for Payer: Group Health Inc Medicare	$1,540.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,200.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,200.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,860.00

TIBIA PSN STM 5 DEG SZ G L

Facility IP

$4,400.00

Service Code	HCPCS C1776
Hospital Charge Code	40204652
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.00
Max. Negotiated Rate	$2,200.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,200.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,200.00

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