St. Barnabas Hospital

All Charges

Charge

Type

Price

DEPUY TOTAL HIP CUP

Facility OP

$4,250.00

Service Code	HCPCS C1776
Hospital Charge Code	40029542
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$4,462.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,337.50
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	$2,125.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,443.75
Rate for Payer: Fidelis Medicare Advantage	$4,462.50
Rate for Payer: Group Health Inc Commercial	$2,125.00
Rate for Payer: Group Health Inc Medicare	$1,487.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,125.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,125.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,762.50

DEPUY TOTAL HIP CUP

Facility IP

$4,250.00

Service Code	HCPCS C1776
Hospital Charge Code	40029542
Hospital Revenue Code	278
Min. Negotiated Rate	$2,125.00
Max. Negotiated Rate	$2,125.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,125.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2,125.00

DEPUY TOTAL HIP FEM HEAD

Facility OP

$2,090.00

Service Code	HCPCS C1776
Hospital Charge Code	40029540
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$2,194.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,149.50
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	$1,045.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,201.75
Rate for Payer: Fidelis Medicare Advantage	$2,194.50
Rate for Payer: Group Health Inc Commercial	$1,045.00
Rate for Payer: Group Health Inc Medicare	$731.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,045.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,045.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,358.50

DEPUY TOTAL HIP FEM HEAD

Facility IP

$2,090.00

Service Code	HCPCS C1776
Hospital Charge Code	40029540
Hospital Revenue Code	278
Min. Negotiated Rate	$1,045.00
Max. Negotiated Rate	$1,045.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,045.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,045.00

DEPUY TOTAL HIP LINER

Facility OP

$2,830.00

Service Code	HCPCS C1776
Hospital Charge Code	40029543
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$2,971.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,556.50
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	$1,415.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,627.25
Rate for Payer: Fidelis Medicare Advantage	$2,971.50
Rate for Payer: Group Health Inc Commercial	$1,415.00
Rate for Payer: Group Health Inc Medicare	$990.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,415.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,415.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,839.50

DEPUY TOTAL HIP LINER

Facility IP

$2,830.00

Service Code	HCPCS C1776
Hospital Charge Code	40029543
Hospital Revenue Code	278
Min. Negotiated Rate	$1,415.00
Max. Negotiated Rate	$1,415.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,415.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,415.00

DEPUY TOTAL HIP STEM

Facility IP

$11,920.00

Service Code	HCPCS C1776
Hospital Charge Code	40029541
Hospital Revenue Code	278
Min. Negotiated Rate	$5,960.00
Max. Negotiated Rate	$5,960.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,960.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,960.00

DEPUY TOTAL HIP STEM

Facility OP

$11,920.00

Service Code	HCPCS C1776
Hospital Charge Code	40029541
Hospital Revenue Code	278
Min. Negotiated Rate	$339.17
Max. Negotiated Rate	$12,516.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6,556.00
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	$5,960.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$6,854.00
Rate for Payer: Fidelis Medicare Advantage	$12,516.00
Rate for Payer: Group Health Inc Commercial	$5,960.00
Rate for Payer: Group Health Inc Medicare	$4,172.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,960.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,960.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7,748.00

DEPUY TRANS ROD 110

Facility OP

$580.00

Service Code	HCPCS C1713
Hospital Charge Code	40029570
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$609.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$319.00
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	$290.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$333.50
Rate for Payer: Fidelis Medicare Advantage	$609.00
Rate for Payer: Group Health Inc Commercial	$290.00
Rate for Payer: Group Health Inc Medicare	$203.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$290.00
Rate for Payer: Hamaspik Choice Inc Medicare	$290.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$377.00

DEPUY TRANS ROD 110

Facility IP

$580.00

Service Code	HCPCS C1713
Hospital Charge Code	40029570
Hospital Revenue Code	278
Min. Negotiated Rate	$290.00
Max. Negotiated Rate	$290.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$290.00
Rate for Payer: Hamaspik Choice Inc Medicare	$290.00

DEPUY TRANSVERSE CONNECTOR

Facility OP

$1,800.23

Hospital Charge Code	40024027
Hospital Revenue Code	279
Min. Negotiated Rate	$630.08
Max. Negotiated Rate	$1,440.18
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$990.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$900.12
Rate for Payer: Aetna Government	$900.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,440.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,224.16
Rate for Payer: Group Health Inc Commercial	$900.12
Rate for Payer: Group Health Inc Medicare	$630.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$900.12
Rate for Payer: Hamaspik Choice Inc Medicare	$900.12

DEPUY UNIPLATE 14MM

Facility OP

$2,550.00

Service Code	HCPCS C1713
Hospital Charge Code	40209924
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,677.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,402.50
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	$1,275.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,466.25
Rate for Payer: Fidelis Medicare Advantage	$2,677.50
Rate for Payer: Group Health Inc Commercial	$1,275.00
Rate for Payer: Group Health Inc Medicare	$892.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,275.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,275.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,657.50

DEPUY UNIPLATE 14MM

Facility IP

$2,550.00

Service Code	HCPCS C1713
Hospital Charge Code	40209924
Hospital Revenue Code	278
Min. Negotiated Rate	$1,275.00
Max. Negotiated Rate	$1,275.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,275.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,275.00

DEPUY UNIPLATE 16MM

Facility IP

$2,550.00

Service Code	HCPCS C1713
Hospital Charge Code	40205383
Hospital Revenue Code	278
Min. Negotiated Rate	$1,275.00
Max. Negotiated Rate	$1,275.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,275.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,275.00

DEPUY UNIPLATE 16MM

Facility OP

$2,550.00

Service Code	HCPCS C1713
Hospital Charge Code	40205383
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,677.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,402.50
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	$1,275.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,466.25
Rate for Payer: Fidelis Medicare Advantage	$2,677.50
Rate for Payer: Group Health Inc Commercial	$1,275.00
Rate for Payer: Group Health Inc Medicare	$892.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,275.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,275.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,657.50

DEPUY UNIPLATE 18MM

Facility OP

$2,550.00

Service Code	HCPCS C1713
Hospital Charge Code	40209925
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$2,677.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,402.50
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	$1,275.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,466.25
Rate for Payer: Fidelis Medicare Advantage	$2,677.50
Rate for Payer: Group Health Inc Commercial	$1,275.00
Rate for Payer: Group Health Inc Medicare	$892.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,275.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,275.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,657.50

DEPUY UNIPLATE 18MM

Facility IP

$2,550.00

Service Code	HCPCS C1713
Hospital Charge Code	40209925
Hospital Revenue Code	278
Min. Negotiated Rate	$1,275.00
Max. Negotiated Rate	$1,275.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,275.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,275.00

DEPUY WIDE HOOK

Facility OP

$2,182.95

Hospital Charge Code	40024028
Hospital Revenue Code	279
Min. Negotiated Rate	$764.03
Max. Negotiated Rate	$1,746.36
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,200.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,091.48
Rate for Payer: Aetna Government	$1,091.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,746.36
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,484.41
Rate for Payer: Group Health Inc Commercial	$1,091.48
Rate for Payer: Group Health Inc Medicare	$764.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,091.48
Rate for Payer: Hamaspik Choice Inc Medicare	$1,091.48

DERMABOND .5ML - KIT

Facility OP

$48.00

Hospital Charge Code	41657072
Hospital Revenue Code	250
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$38.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$26.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$24.00
Rate for Payer: Aetna Government	$24.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$38.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$32.64
Rate for Payer: Group Health Inc Commercial	$24.00
Rate for Payer: Group Health Inc Medicare	$16.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$24.00
Rate for Payer: Hamaspik Choice Inc Medicare	$24.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$31.20

DERMABOND .5ML - KIT

Facility OP

$48.00

Hospital Charge Code	41647072
Hospital Revenue Code	250
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$38.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$26.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$24.00
Rate for Payer: Aetna Government	$24.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$38.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$32.64
Rate for Payer: Group Health Inc Commercial	$24.00
Rate for Payer: Group Health Inc Medicare	$16.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$24.00
Rate for Payer: Hamaspik Choice Inc Medicare	$24.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$31.20

DERMABOND .5ML - REFILL

Facility OP

$48.00

Hospital Charge Code	41657073
Hospital Revenue Code	250
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$38.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$26.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$24.00
Rate for Payer: Aetna Government	$24.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$38.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$32.64
Rate for Payer: Group Health Inc Commercial	$24.00
Rate for Payer: Group Health Inc Medicare	$16.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$24.00
Rate for Payer: Hamaspik Choice Inc Medicare	$24.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$31.20

DERMABOND .5ML - REFILL

Facility OP

$48.00

Hospital Charge Code	41647073
Hospital Revenue Code	250
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$38.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$26.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$24.00
Rate for Payer: Aetna Government	$24.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$38.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$32.64
Rate for Payer: Group Health Inc Commercial	$24.00
Rate for Payer: Group Health Inc Medicare	$16.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$24.00
Rate for Payer: Hamaspik Choice Inc Medicare	$24.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$31.20

DERMAGRAFT 2X3 (11045)

Facility IP

$562.50

Service Code	HCPCS Q4106
Hospital Charge Code	64901193
Hospital Revenue Code	636
Min. Negotiated Rate	$281.25
Max. Negotiated Rate	$281.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$281.25
Rate for Payer: Hamaspik Choice Inc Medicare	$281.25

DERMAGRAFT 2X3 (11045)

Facility OP

$562.50

Service Code	HCPCS Q4106
Hospital Charge Code	64901193
Hospital Revenue Code	636
Min. Negotiated Rate	$31.03
Max. Negotiated Rate	$365.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$309.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$32.03
Rate for Payer: Aetna Government	$32.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$281.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$323.44
Rate for Payer: Fidelis CHP/HARP/Medicaid	$31.03
Rate for Payer: Group Health Inc Commercial	$281.25
Rate for Payer: Group Health Inc Medicare	$196.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$281.25
Rate for Payer: Hamaspik Choice Inc Medicare	$281.25
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$34.48
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$365.62

DERMAGRAFT PER 1 SQ CM

Facility OP

$81.06

Service Code	HCPCS Q4106
Hospital Charge Code	42500213
Hospital Revenue Code	636
Min. Negotiated Rate	$28.37
Max. Negotiated Rate	$52.69
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$44.58
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$32.03
Rate for Payer: Aetna Government	$32.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$40.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$46.61
Rate for Payer: Fidelis CHP/HARP/Medicaid	$31.03
Rate for Payer: Group Health Inc Commercial	$40.53
Rate for Payer: Group Health Inc Medicare	$28.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$40.53
Rate for Payer: Hamaspik Choice Inc Medicare	$40.53
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$34.48
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$52.69

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