St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

SHEET ORBITL MICROTHIN 30X50X.4MM

Facility

$1,232.50

Service Code	HCPCS C1713
Hospital Charge Code	64902573
Hospital Revenue Code	278
Min. Negotiated Rate	$616.25
Max. Negotiated Rate	$616.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$616.25
Rate for Payer: Hamaspik Choice Inc Medicare	$616.25

SHEET ORBITL MICROTHIN 30X50X.4MM

Facility

$1,232.50

Service Code	HCPCS C1713
Hospital Charge Code	64902573
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$1,294.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$677.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$739.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$616.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$708.69
Rate for Payer: EmblemHealth Commercial	$616.25
Rate for Payer: Fidelis Medicare Advantage	$1,294.12
Rate for Payer: Group Health Inc Commercial	$616.25
Rate for Payer: Group Health Inc Medicare	$431.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$616.25
Rate for Payer: Hamaspik Choice Inc Medicare	$616.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$801.12

SHELL 52MM BIPOLAR

Facility

$1,638.00

Service Code	HCPCS C1776
Hospital Charge Code	64906920
Hospital Revenue Code	278
Min. Negotiated Rate	$819.00
Max. Negotiated Rate	$819.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$819.00
Rate for Payer: Hamaspik Choice Inc Medicare	$819.00

SHELL 52MM BIPOLAR

Facility

$1,638.00

Service Code	HCPCS C1776
Hospital Charge Code	64906920
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$1,719.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$900.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$982.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$819.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$941.85
Rate for Payer: EmblemHealth Commercial	$819.00
Rate for Payer: Fidelis Medicare Advantage	$1,719.90
Rate for Payer: Group Health Inc Commercial	$819.00
Rate for Payer: Group Health Inc Medicare	$573.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$819.00
Rate for Payer: Hamaspik Choice Inc Medicare	$819.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,064.70

SHELL ACETABULAR CLUSTERHOLE

Facility

$8,185.50

Service Code	HCPCS C1776
Hospital Charge Code	64904695
Hospital Revenue Code	278
Min. Negotiated Rate	$4,092.75
Max. Negotiated Rate	$4,092.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,092.75
Rate for Payer: Hamaspik Choice Inc Medicare	$4,092.75

SHELL ACETABULAR CLUSTERHOLE

Facility

$8,185.50

Service Code	HCPCS C1776
Hospital Charge Code	64904695
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$8,594.78
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,502.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$4,911.30
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4,092.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,706.66
Rate for Payer: EmblemHealth Commercial	$4,092.75
Rate for Payer: Fidelis Medicare Advantage	$8,594.78
Rate for Payer: Group Health Inc Commercial	$4,092.75
Rate for Payer: Group Health Inc Medicare	$2,864.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,092.75
Rate for Payer: Hamaspik Choice Inc Medicare	$4,092.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,320.58

SHELL ACETABULAR HOLEX3 48MM O

Facility

$3,754.13

Service Code	HCPCS C1776
Hospital Charge Code	64904381
Hospital Revenue Code	278
Min. Negotiated Rate	$1,877.06
Max. Negotiated Rate	$1,877.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,877.06
Rate for Payer: Hamaspik Choice Inc Medicare	$1,877.06

SHELL ACETABULAR HOLEX3 48MM O

Facility

$3,754.13

Service Code	HCPCS C1776
Hospital Charge Code	64904381
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$3,941.84
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,064.77
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,252.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,877.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,158.62
Rate for Payer: EmblemHealth Commercial	$1,877.06
Rate for Payer: Fidelis Medicare Advantage	$3,941.84
Rate for Payer: Group Health Inc Commercial	$1,877.06
Rate for Payer: Group Health Inc Medicare	$1,313.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,877.06
Rate for Payer: Hamaspik Choice Inc Medicare	$1,877.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,440.18

SHELL ACETABULAR HOLEX3 50MM O

Facility

$3,754.13

Service Code	HCPCS C1776
Hospital Charge Code	64903152
Hospital Revenue Code	278
Min. Negotiated Rate	$1,877.06
Max. Negotiated Rate	$1,877.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,877.06
Rate for Payer: Hamaspik Choice Inc Medicare	$1,877.06

SHELL ACETABULAR HOLEX3 50MM O

Facility

$3,754.13

Service Code	HCPCS C1776
Hospital Charge Code	64903152
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$3,941.84
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,064.77
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,252.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,877.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,158.62
Rate for Payer: EmblemHealth Commercial	$1,877.06
Rate for Payer: Fidelis Medicare Advantage	$3,941.84
Rate for Payer: Group Health Inc Commercial	$1,877.06
Rate for Payer: Group Health Inc Medicare	$1,313.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,877.06
Rate for Payer: Hamaspik Choice Inc Medicare	$1,877.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,440.18

SHELL BIPOLAR CUP 55MM O.D.

Facility

$1,638.00

Service Code	HCPCS C1776
Hospital Charge Code	64906593
Hospital Revenue Code	278
Min. Negotiated Rate	$819.00
Max. Negotiated Rate	$819.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$819.00
Rate for Payer: Hamaspik Choice Inc Medicare	$819.00

SHELL BIPOLAR CUP 55MM O.D.

Facility

$1,638.00

Service Code	HCPCS C1776
Hospital Charge Code	64906593
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$1,719.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$900.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$982.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$819.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$941.85
Rate for Payer: EmblemHealth Commercial	$819.00
Rate for Payer: Fidelis Medicare Advantage	$1,719.90
Rate for Payer: Group Health Inc Commercial	$819.00
Rate for Payer: Group Health Inc Medicare	$573.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$819.00
Rate for Payer: Hamaspik Choice Inc Medicare	$819.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,064.70

SHELL BIPOLAR OD 5001

Facility

$2,047.50

Service Code	HCPCS C1776
Hospital Charge Code	64907024
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$2,149.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,126.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$1,228.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,023.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,177.31
Rate for Payer: EmblemHealth Commercial	$1,023.75
Rate for Payer: Fidelis Medicare Advantage	$2,149.88
Rate for Payer: Group Health Inc Commercial	$1,023.75
Rate for Payer: Group Health Inc Medicare	$716.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,023.75
Rate for Payer: Hamaspik Choice Inc Medicare	$1,023.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,330.88

SHELL BIPOLAR OD 5001

Facility

$2,047.50

Service Code	HCPCS C1776
Hospital Charge Code	64907024
Hospital Revenue Code	278
Min. Negotiated Rate	$1,023.75
Max. Negotiated Rate	$1,023.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,023.75
Rate for Payer: Hamaspik Choice Inc Medicare	$1,023.75

SHELL CONT CLUS 64OO 00875706401

Facility

$1,900.00

Service Code	HCPCS C1776
Hospital Charge Code	64906454
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$1,995.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,045.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$1,140.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$950.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,092.50
Rate for Payer: EmblemHealth Commercial	$950.00
Rate for Payer: Fidelis Medicare Advantage	$1,995.00
Rate for Payer: Group Health Inc Commercial	$950.00
Rate for Payer: Group Health Inc Medicare	$665.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$950.00
Rate for Payer: Hamaspik Choice Inc Medicare	$950.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,235.00

SHELL CONT CLUS 64OO 00875706401

Facility

$1,900.00

Service Code	HCPCS C1776
Hospital Charge Code	64906454
Hospital Revenue Code	278
Min. Negotiated Rate	$950.00
Max. Negotiated Rate	$950.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$950.00
Rate for Payer: Hamaspik Choice Inc Medicare	$950.00

SHELL CONT MULTI-HOLE 60 MM

Facility

$9,900.00

Hospital Charge Code	64906175
Hospital Revenue Code	270
Min. Negotiated Rate	$3,465.00
Max. Negotiated Rate	$7,920.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,445.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4,950.00
Rate for Payer: Aetna Government	$4,950.00
Rate for Payer: Brighton Health Commercial	$7,425.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7,920.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$6,732.00
Rate for Payer: Group Health Inc Commercial	$4,950.00
Rate for Payer: Group Health Inc Medicare	$3,465.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,950.00
Rate for Payer: Hamaspik Choice Inc Medicare	$4,950.00

SHELL CONT MULT SHELL 54 JJ

Facility

$7,425.00

Service Code	HCPCS C1713
Hospital Charge Code	64905853
Hospital Revenue Code	278
Min. Negotiated Rate	$3,712.50
Max. Negotiated Rate	$3,712.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,712.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3,712.50

SHELL CONT MULT SHELL 54 JJ

Facility

$7,425.00

Service Code	HCPCS C1713
Hospital Charge Code	64905853
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$7,796.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,083.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$4,455.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,712.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,269.38
Rate for Payer: EmblemHealth Commercial	$3,712.50
Rate for Payer: Fidelis Medicare Advantage	$7,796.25
Rate for Payer: Group Health Inc Commercial	$3,712.50
Rate for Payer: Group Health Inc Medicare	$2,598.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,712.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3,712.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,826.25

SHELL CUP BIPOLAR 47MM OD 5001-47

Facility

$1,638.00

Hospital Charge Code	64906538
Hospital Revenue Code	279
Min. Negotiated Rate	$573.30
Max. Negotiated Rate	$1,310.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$900.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$819.00
Rate for Payer: Aetna Government	$819.00
Rate for Payer: Brighton Health Commercial	$1,228.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,310.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,113.84
Rate for Payer: Group Health Inc Commercial	$819.00
Rate for Payer: Group Health Inc Medicare	$573.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$819.00
Rate for Payer: Hamaspik Choice Inc Medicare	$819.00

SHELL G7 OSSEO 4HOLE 60MM

Facility

$4,750.00

Service Code	HCPCS C1776
Hospital Charge Code	64906966
Hospital Revenue Code	278
Min. Negotiated Rate	$2,375.00
Max. Negotiated Rate	$2,375.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,375.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,375.00

SHELL G7 OSSEO 4HOLE 60MM

Facility

$4,750.00

Service Code	HCPCS C1776
Hospital Charge Code	64906966
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$4,987.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,612.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,850.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,375.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,731.25
Rate for Payer: EmblemHealth Commercial	$2,375.00
Rate for Payer: Fidelis Medicare Advantage	$4,987.50
Rate for Payer: Group Health Inc Commercial	$2,375.00
Rate for Payer: Group Health Inc Medicare	$1,662.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,375.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,375.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3,087.50

SHELL G7 OSSEO 54MM F

Facility

$3,800.00

Service Code	HCPCS C1776
Hospital Charge Code	64906938
Hospital Revenue Code	278
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$1,900.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,900.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,900.00

SHELL G7 OSSEO 54MM F

Facility

$3,800.00

Service Code	HCPCS C1776
Hospital Charge Code	64906938
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$3,990.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,090.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$339.17
Rate for Payer: Aetna Government	$339.17
Rate for Payer: Brighton Health Commercial	$2,280.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,900.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,185.00
Rate for Payer: EmblemHealth Commercial	$1,900.00
Rate for Payer: Fidelis Medicare Advantage	$3,990.00
Rate for Payer: Group Health Inc Commercial	$1,900.00
Rate for Payer: Group Health Inc Medicare	$1,330.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,900.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,900.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,470.00

SHELL METAL 56 OD KK W/CLUS 601

Facility

$3,800.00

Hospital Charge Code	64906700
Hospital Revenue Code	279
Min. Negotiated Rate	$1,330.00
Max. Negotiated Rate	$3,040.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,090.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,900.00
Rate for Payer: Aetna Government	$1,900.00
Rate for Payer: Brighton Health Commercial	$2,850.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,040.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,584.00
Rate for Payer: Group Health Inc Commercial	$1,900.00
Rate for Payer: Group Health Inc Medicare	$1,330.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,900.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,900.00

Know your out-of-pocket cost for care.

All Charges