St. Barnabas Hospital

All Charges

Charge

Type

Price

COMPONENT DST FEM RV SZB RT

Facility OP

$12,120.00

Service Code	HCPCS C1776
Hospital Charge Code	64906415
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$12,726.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6,666.00
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	$6,060.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$6,969.00
Rate for Payer: Fidelis Medicare Advantage	$12,726.00
Rate for Payer: Group Health Inc Commercial	$6,060.00
Rate for Payer: Group Health Inc Medicare	$4,242.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$6,060.00
Rate for Payer: Hamaspik Choice Inc Medicare	$6,060.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7,878.00

COMPONENT DST FEM RV SZB RT

Facility IP

$12,120.00

Service Code	HCPCS C1776
Hospital Charge Code	64906415
Hospital Revenue Code	278
Min. Negotiated Rate	$6,060.00
Max. Negotiated Rate	$6,060.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$6,060.00
Rate for Payer: Hamaspik Choice Inc Medicare	$6,060.00

COMPONENT FEMORAL A

Facility OP

$8,183.38

Service Code	HCPCS C1713
Hospital Charge Code	64901701
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$8,592.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,500.86
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	$4,091.69
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,705.44
Rate for Payer: Fidelis Medicare Advantage	$8,592.55
Rate for Payer: Group Health Inc Commercial	$4,091.69
Rate for Payer: Group Health Inc Medicare	$2,864.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,091.69
Rate for Payer: Hamaspik Choice Inc Medicare	$4,091.69
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,319.20

COMPONENT FEMORAL A

Facility IP

$8,183.38

Service Code	HCPCS C1713
Hospital Charge Code	64901701
Hospital Revenue Code	278
Min. Negotiated Rate	$4,091.69
Max. Negotiated Rate	$4,091.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,091.69
Rate for Payer: Hamaspik Choice Inc Medicare	$4,091.69

COMPONENT FEMORAL B

Facility IP

$10,467.75

Service Code	HCPCS C1713
Hospital Charge Code	64901831
Hospital Revenue Code	278
Min. Negotiated Rate	$5,233.88
Max. Negotiated Rate	$5,233.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,233.88
Rate for Payer: Hamaspik Choice Inc Medicare	$5,233.88

COMPONENT FEMORAL B

Facility OP

$10,467.75

Service Code	HCPCS C1713
Hospital Charge Code	64901831
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$10,991.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,757.26
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	$5,233.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$6,018.96
Rate for Payer: Fidelis Medicare Advantage	$10,991.14
Rate for Payer: Group Health Inc Commercial	$5,233.88
Rate for Payer: Group Health Inc Medicare	$3,663.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,233.88
Rate for Payer: Hamaspik Choice Inc Medicare	$5,233.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$6,804.04

COMPONENT FEMORAL SIZE 6 OXINI

Facility IP

$9,705.00

Service Code	HCPCS C1713
Hospital Charge Code	64903669
Hospital Revenue Code	278
Min. Negotiated Rate	$4,852.50
Max. Negotiated Rate	$4,852.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,852.50
Rate for Payer: Hamaspik Choice Inc Medicare	$4,852.50

COMPONENT FEMORAL SIZE 6 OXINI

Facility OP

$9,705.00

Service Code	HCPCS C1713
Hospital Charge Code	64903669
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$10,190.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,337.75
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	$4,852.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$5,580.38
Rate for Payer: Fidelis Medicare Advantage	$10,190.25
Rate for Payer: Group Health Inc Commercial	$4,852.50
Rate for Payer: Group Health Inc Medicare	$3,396.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,852.50
Rate for Payer: Hamaspik Choice Inc Medicare	$4,852.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$6,308.25

COMPONENT FEMORAL SIZE E RT

Facility IP

$8,183.38

Service Code	HCPCS C1713
Hospital Charge Code	64901353
Hospital Revenue Code	278
Min. Negotiated Rate	$4,091.69
Max. Negotiated Rate	$4,091.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,091.69
Rate for Payer: Hamaspik Choice Inc Medicare	$4,091.69

COMPONENT FEMORAL SIZE E RT

Facility OP

$8,183.38

Service Code	HCPCS C1713
Hospital Charge Code	64901353
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$8,592.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,500.86
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	$4,091.69
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,705.44
Rate for Payer: Fidelis Medicare Advantage	$8,592.55
Rate for Payer: Group Health Inc Commercial	$4,091.69
Rate for Payer: Group Health Inc Medicare	$2,864.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$4,091.69
Rate for Payer: Hamaspik Choice Inc Medicare	$4,091.69
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,319.20

COMPONENT FEMORAL SZ 4 COBALT

Facility IP

$6,744.25

Service Code	HCPCS C1713
Hospital Charge Code	64904595
Hospital Revenue Code	278
Min. Negotiated Rate	$3,372.12
Max. Negotiated Rate	$3,372.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,372.12
Rate for Payer: Hamaspik Choice Inc Medicare	$3,372.12

COMPONENT FEMORAL SZ 4 COBALT

Facility OP

$6,744.25

Service Code	HCPCS C1713
Hospital Charge Code	64904595
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$7,081.46
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,709.34
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	$3,372.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,877.94
Rate for Payer: Fidelis Medicare Advantage	$7,081.46
Rate for Payer: Group Health Inc Commercial	$3,372.12
Rate for Payer: Group Health Inc Medicare	$2,360.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,372.12
Rate for Payer: Hamaspik Choice Inc Medicare	$3,372.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,383.76

COMPONENT FEMORAL SZ E RT

Facility IP

$6,912.00

Service Code	HCPCS C1776
Hospital Charge Code	40204056
Hospital Revenue Code	278
Min. Negotiated Rate	$3,456.00
Max. Negotiated Rate	$3,456.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,456.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,456.00

COMPONENT FEMORAL SZ E RT

Facility OP

$6,912.00

Service Code	HCPCS C1776
Hospital Charge Code	40204056
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$7,257.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3,801.60
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	$3,456.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,974.40
Rate for Payer: Fidelis Medicare Advantage	$7,257.60
Rate for Payer: Group Health Inc Commercial	$3,456.00
Rate for Payer: Group Health Inc Medicare	$2,419.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,456.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,456.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4,492.80

COMPONENT FEMOR CMNTD SZ6 L

Facility IP

$7,750.00

Service Code	HCPCS C1713
Hospital Charge Code	64905773
Hospital Revenue Code	278
Min. Negotiated Rate	$3,875.00
Max. Negotiated Rate	$3,875.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,875.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,875.00

COMPONENT FEMOR CMNTD SZ6 L

Facility OP

$7,750.00

Service Code	HCPCS C1713
Hospital Charge Code	64905773
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$8,137.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,262.50
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	$3,875.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,456.25
Rate for Payer: Fidelis Medicare Advantage	$8,137.50
Rate for Payer: Group Health Inc Commercial	$3,875.00
Rate for Payer: Group Health Inc Medicare	$2,712.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,875.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,875.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,037.50

COMPONENT FEMOR CMNTED SZ3

Facility OP

$7,750.00

Service Code	HCPCS C1713
Hospital Charge Code	64905752
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$8,137.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,262.50
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	$3,875.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,456.25
Rate for Payer: Fidelis Medicare Advantage	$8,137.50
Rate for Payer: Group Health Inc Commercial	$3,875.00
Rate for Payer: Group Health Inc Medicare	$2,712.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,875.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,875.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,037.50

COMPONENT FEMOR CMNTED SZ3

Facility IP

$7,750.00

Service Code	HCPCS C1713
Hospital Charge Code	64905752
Hospital Revenue Code	278
Min. Negotiated Rate	$3,875.00
Max. Negotiated Rate	$3,875.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,875.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,875.00

COMPONENT FEMOR CMNTED SZ6

Facility IP

$7,750.00

Service Code	HCPCS C1713
Hospital Charge Code	64905749
Hospital Revenue Code	278
Min. Negotiated Rate	$3,875.00
Max. Negotiated Rate	$3,875.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,875.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,875.00

COMPONENT FEMOR CMNTED SZ6

Facility OP

$7,750.00

Service Code	HCPCS C1713
Hospital Charge Code	64905749
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$8,137.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,262.50
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	$3,875.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,456.25
Rate for Payer: Fidelis Medicare Advantage	$8,137.50
Rate for Payer: Group Health Inc Commercial	$3,875.00
Rate for Payer: Group Health Inc Medicare	$2,712.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,875.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,875.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,037.50

COMPONENT FEMOR CMTD SZ8 L

Facility IP

$7,750.00

Service Code	HCPCS C1713
Hospital Charge Code	64905769
Hospital Revenue Code	278
Min. Negotiated Rate	$3,875.00
Max. Negotiated Rate	$3,875.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,875.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,875.00

COMPONENT FEMOR CMTD SZ8 L

Facility OP

$7,750.00

Service Code	HCPCS C1713
Hospital Charge Code	64905769
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$8,137.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,262.50
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	$3,875.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,456.25
Rate for Payer: Fidelis Medicare Advantage	$8,137.50
Rate for Payer: Group Health Inc Commercial	$3,875.00
Rate for Payer: Group Health Inc Medicare	$2,712.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,875.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,875.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,037.50

COMPONENT FEM RGHT SZ4

Facility IP

$7,750.00

Service Code	HCPCS C1776
Hospital Charge Code	64905821
Hospital Revenue Code	278
Min. Negotiated Rate	$3,875.00
Max. Negotiated Rate	$3,875.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,875.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,875.00

COMPONENT FEM RGHT SZ4

Facility OP

$7,750.00

Service Code	HCPCS C1776
Hospital Charge Code	64905821
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$8,137.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4,262.50
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	$3,875.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$4,456.25
Rate for Payer: Fidelis Medicare Advantage	$8,137.50
Rate for Payer: Group Health Inc Commercial	$3,875.00
Rate for Payer: Group Health Inc Medicare	$2,712.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3,875.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3,875.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5,037.50

COMPONENT MODULAR HEAD 28MM

Facility IP

$1,222.00

Service Code	HCPCS C1776
Hospital Charge Code	40209660
Hospital Revenue Code	278
Min. Negotiated Rate	$611.00
Max. Negotiated Rate	$611.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$611.00
Rate for Payer: Hamaspik Choice Inc Medicare	$611.00

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