St. Barnabas Hospital

All Charges

Charge

Type

Price

11X300MM X 125 RIGHT

Facility OP

$2,650.00

Service Code	HCPCS C1713
Hospital Charge Code	40200575
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,782.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,457.50
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	$1,325.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,523.75
Rate for Payer: Fidelis Medicare Advantage	$2,782.50
Rate for Payer: Group Health Inc Commercial	$1,325.00
Rate for Payer: Group Health Inc Medicare	$927.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,325.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,325.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,722.50

11X300 T2 TIBIAL NAIL, STANDARD

Facility IP

$2,364.60

Service Code	HCPCS C1713
Hospital Charge Code	40200574
Hospital Revenue Code	278
Min. Negotiated Rate	$1,182.30
Max. Negotiated Rate	$1,182.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,182.30
Rate for Payer: Hamaspik Choice Inc Medicare	$1,182.30

11X300 T2 TIBIAL NAIL, STANDARD

Facility OP

$2,364.60

Service Code	HCPCS C1713
Hospital Charge Code	40200574
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,482.83
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,300.53
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	$1,182.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,359.64
Rate for Payer: Fidelis Medicare Advantage	$2,482.83
Rate for Payer: Group Health Inc Commercial	$1,182.30
Rate for Payer: Group Health Inc Medicare	$827.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,182.30
Rate for Payer: Hamaspik Choice Inc Medicare	$1,182.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,536.99

11X330MM T2 TIBIAL NAIL, STANDARD

Facility OP

$2,264.00

Service Code	HCPCS C1713
Hospital Charge Code	40200576
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,377.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,245.20
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	$1,132.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,301.80
Rate for Payer: Fidelis Medicare Advantage	$2,377.20
Rate for Payer: Group Health Inc Commercial	$1,132.00
Rate for Payer: Group Health Inc Medicare	$792.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,132.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,132.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,471.60

11X330MM T2 TIBIAL NAIL, STANDARD

Facility IP

$2,264.00

Service Code	HCPCS C1713
Hospital Charge Code	40200576
Hospital Revenue Code	278
Min. Negotiated Rate	$1,132.00
Max. Negotiated Rate	$1,132.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,132.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,132.00

11X340X125 DEGREE RIGHT

Facility OP

$2,650.00

Service Code	HCPCS C1713
Hospital Charge Code	40203000
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,782.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,457.50
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	$1,325.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,523.75
Rate for Payer: Fidelis Medicare Advantage	$2,782.50
Rate for Payer: Group Health Inc Commercial	$1,325.00
Rate for Payer: Group Health Inc Medicare	$927.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,325.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,325.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,722.50

11X340X125 DEGREE RIGHT

Facility IP

$2,650.00

Service Code	HCPCS C1713
Hospital Charge Code	40203000
Hospital Revenue Code	278
Min. Negotiated Rate	$1,325.00
Max. Negotiated Rate	$1,325.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,325.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,325.00

11X345MM T2 TIBIAL NAIL, STANDARD

Facility IP

$2,264.00

Service Code	HCPCS C1776
Hospital Charge Code	40200578
Hospital Revenue Code	278
Min. Negotiated Rate	$1,132.00
Max. Negotiated Rate	$1,132.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,132.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,132.00

11X345MM T2 TIBIAL NAIL, STANDARD

Facility OP

$2,264.00

Service Code	HCPCS C1776
Hospital Charge Code	40200578
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$2,377.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,245.20
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	$1,132.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,301.80
Rate for Payer: Fidelis Medicare Advantage	$2,377.20
Rate for Payer: Group Health Inc Commercial	$1,132.00
Rate for Payer: Group Health Inc Medicare	$792.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,132.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,132.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,471.60

11X360MMX125 DEGREE LEFT

Facility OP

$3,150.00

Service Code	HCPCS C1713
Hospital Charge Code	40200580
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$3,307.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,732.50
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	$1,575.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,811.25
Rate for Payer: Fidelis Medicare Advantage	$3,307.50
Rate for Payer: Group Health Inc Commercial	$1,575.00
Rate for Payer: Group Health Inc Medicare	$1,102.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,575.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,575.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,047.50

11X360MMX125 DEGREE LEFT

Facility IP

$3,150.00

Service Code	HCPCS C1713
Hospital Charge Code	40200580
Hospital Revenue Code	278
Min. Negotiated Rate	$1,575.00
Max. Negotiated Rate	$1,575.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,575.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,575.00

11X360X125 DEGREE RIGHT

Facility IP

$3,150.00

Service Code	HCPCS C1713
Hospital Charge Code	40200579
Hospital Revenue Code	278
Min. Negotiated Rate	$1,575.00
Max. Negotiated Rate	$1,575.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,575.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,575.00

11X360X125 DEGREE RIGHT

Facility OP

$3,150.00

Service Code	HCPCS C1713
Hospital Charge Code	40200579
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$3,307.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,732.50
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	$1,575.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,811.25
Rate for Payer: Fidelis Medicare Advantage	$3,307.50
Rate for Payer: Group Health Inc Commercial	$1,575.00
Rate for Payer: Group Health Inc Medicare	$1,102.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,575.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,575.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,047.50

11X380MMX124 DEGREE LEFT

Facility OP

$3,150.00

Service Code	HCPCS C1713
Hospital Charge Code	40209921
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$3,307.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,732.50
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	$1,575.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,811.25
Rate for Payer: Fidelis Medicare Advantage	$3,307.50
Rate for Payer: Group Health Inc Commercial	$1,575.00
Rate for Payer: Group Health Inc Medicare	$1,102.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,575.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,575.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,047.50

11X380MMX124 DEGREE LEFT

Facility IP

$3,150.00

Service Code	HCPCS C1713
Hospital Charge Code	40209921
Hospital Revenue Code	278
Min. Negotiated Rate	$1,575.00
Max. Negotiated Rate	$1,575.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,575.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,575.00

11X380MMX125 DEGREE LN KITR2.0LFT

Facility OP

$3,150.00

Service Code	HCPCS C1776
Hospital Charge Code	40208097
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$3,307.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,732.50
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	$1,575.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,811.25
Rate for Payer: Fidelis Medicare Advantage	$3,307.50
Rate for Payer: Group Health Inc Commercial	$1,575.00
Rate for Payer: Group Health Inc Medicare	$1,102.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,575.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,575.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,047.50

11X380MMX125 DEGREE LN KITR2.0LFT

Facility IP

$3,150.00

Service Code	HCPCS C1776
Hospital Charge Code	40208097
Hospital Revenue Code	278
Min. Negotiated Rate	$1,575.00
Max. Negotiated Rate	$1,575.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,575.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,575.00

11X420MMX125 DEGREE RIGHT

Facility IP

$2,940.00

Service Code	HCPCS C1713
Hospital Charge Code	40200581
Hospital Revenue Code	278
Min. Negotiated Rate	$1,470.00
Max. Negotiated Rate	$1,470.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,470.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,470.00

11X420MMX125 DEGREE RIGHT

Facility OP

$2,940.00

Service Code	HCPCS C1713
Hospital Charge Code	40200581
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$3,087.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,617.00
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	$1,470.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,690.50
Rate for Payer: Fidelis Medicare Advantage	$3,087.00
Rate for Payer: Group Health Inc Commercial	$1,470.00
Rate for Payer: Group Health Inc Medicare	$1,029.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,470.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,470.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,911.00

12/14 COCR FEMORAL HEAD 36MM -3.5

Facility IP

$2,544.00

Service Code	HCPCS C1776
Hospital Charge Code	40007529
Hospital Revenue Code	278
Min. Negotiated Rate	$1,272.00
Max. Negotiated Rate	$1,272.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,272.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,272.00

12/14 COCR FEMORAL HEAD 36MM -3.5

Facility OP

$2,544.00

Service Code	HCPCS C1776
Hospital Charge Code	40204610
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$2,671.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,399.20
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	$1,272.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,462.80
Rate for Payer: Fidelis Medicare Advantage	$2,671.20
Rate for Payer: Group Health Inc Commercial	$1,272.00
Rate for Payer: Group Health Inc Medicare	$890.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,272.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,272.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,653.60

12/14 COCR FEMORAL HEAD 36MM -3.5

Facility OP

$2,544.00

Service Code	HCPCS C1776
Hospital Charge Code	40007529
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$2,671.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,399.20
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	$1,272.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,462.80
Rate for Payer: Fidelis Medicare Advantage	$2,671.20
Rate for Payer: Group Health Inc Commercial	$1,272.00
Rate for Payer: Group Health Inc Medicare	$890.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,272.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,272.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,653.60

12/14 COCR FEMORAL HEAD 36MM -3.5

Facility IP

$2,544.00

Service Code	HCPCS C1776
Hospital Charge Code	40204610
Hospital Revenue Code	278
Min. Negotiated Rate	$1,272.00
Max. Negotiated Rate	$1,272.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,272.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,272.00

1,25-DIHYDROXY,VITAMIN D BY MS

Facility OP

$96.25

Service Code	HCPCS 82652
Hospital Charge Code	40609065
Hospital Revenue Code	300
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$61.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$52.94
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$38.50
Rate for Payer: Aetna Government	$38.50
Rate for Payer: Cash Price	$38.50
Rate for Payer: Cash Price	$38.50
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$38.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$61.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$51.79
Rate for Payer: Elderplan Medicare Advantage	$38.50
Rate for Payer: EmblemHealth Commercial	$38.50
Rate for Payer: Fidelis CHP/HARP/Medicaid	$34.65
Rate for Payer: Fidelis Essential Plan Aliesa	$32.72
Rate for Payer: Fidelis Essential Plan QHP	$34.26
Rate for Payer: Fidelis Medicare Advantage	$38.50
Rate for Payer: Fidelis Qualified Health Plan	$34.26
Rate for Payer: Group Health Inc Commercial	$38.50
Rate for Payer: Group Health Inc Medicare	$38.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$48.12
Rate for Payer: Hamaspik Choice Inc Medicare	$38.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$38.50
Rate for Payer: Healthfirst Medicare Advantage	$38.50
Rate for Payer: Healthfirst QHP	$38.50
Rate for Payer: Senior Whole Health Medicare Advantage	$38.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$38.50
Rate for Payer: Wellcare CHP/FHP/Medicaid	$30.80
Rate for Payer: Wellcare Medicare	$34.65

1.2 BURR H COVER PLATE 10MM

Facility OP

$346.00

Service Code	HCPCS C1781
Hospital Charge Code	40209752
Hospital Revenue Code	278
Min. Negotiated Rate	$69.35
Max. Negotiated Rate	$363.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$190.30
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	$173.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$198.95
Rate for Payer: Fidelis Medicare Advantage	$363.30
Rate for Payer: Group Health Inc Commercial	$173.00
Rate for Payer: Group Health Inc Medicare	$121.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$173.00
Rate for Payer: Hamaspik Choice Inc Medicare	$173.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$224.90

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