St. Barnabas Hospital

All Charges

Charge

Type

Price

ALLODERM 9.6 SQCM CM152OP

Facility OP

$11,388.00

Service Code	HCPCS Q4116
Hospital Charge Code	40204565
Hospital Revenue Code	636
Min. Negotiated Rate	$21.47
Max. Negotiated Rate	$7,402.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6,263.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$21.47
Rate for Payer: Aetna Government	$21.47
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5,694.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$6,548.10
Rate for Payer: Group Health Inc Commercial	$5,694.00
Rate for Payer: Group Health Inc Medicare	$3,985.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,694.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,694.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7,402.20

ALLODERM 9.6 SQCM CM152OP

Facility IP

$11,388.00

Service Code	HCPCS Q4116
Hospital Charge Code	40204565
Hospital Revenue Code	636
Min. Negotiated Rate	$5,694.00
Max. Negotiated Rate	$5,694.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,694.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,694.00

ALLODERM CONTOUR 9.6X19.3 MED

Facility OP

$11,388.00

Service Code	HCPCS Q4116
Hospital Charge Code	40007777
Hospital Revenue Code	636
Min. Negotiated Rate	$21.47
Max. Negotiated Rate	$7,402.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6,263.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$21.47
Rate for Payer: Aetna Government	$21.47
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5,694.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$6,548.10
Rate for Payer: Group Health Inc Commercial	$5,694.00
Rate for Payer: Group Health Inc Medicare	$3,985.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,694.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,694.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7,402.20

ALLODERM CONTOUR 9.6X19.3 MED

Facility IP

$11,388.00

Service Code	HCPCS Q4116
Hospital Charge Code	40007777
Hospital Revenue Code	636
Min. Negotiated Rate	$5,694.00
Max. Negotiated Rate	$5,694.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,694.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,694.00

ALLODERM CONTOUR MED 132CMX1.0MM

Facility IP

$11,052.00

Service Code	HCPCS Q4116
Hospital Charge Code	40007778
Hospital Revenue Code	636
Min. Negotiated Rate	$5,526.00
Max. Negotiated Rate	$5,526.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,526.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,526.00

ALLODERM CONTOUR MED 132CMX1.0MM

Facility OP

$11,052.00

Service Code	HCPCS Q4116
Hospital Charge Code	40007778
Hospital Revenue Code	636
Min. Negotiated Rate	$21.47
Max. Negotiated Rate	$7,183.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6,078.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$21.47
Rate for Payer: Aetna Government	$21.47
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5,526.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$6,354.90
Rate for Payer: Group Health Inc Commercial	$5,526.00
Rate for Payer: Group Health Inc Medicare	$3,868.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,526.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,526.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7,183.80

ALLODERM CONTOUR MED THIN

Facility IP

$57.56

Service Code	HCPCS Q4116
Hospital Charge Code	64905426
Hospital Revenue Code	636
Min. Negotiated Rate	$28.78
Max. Negotiated Rate	$28.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$28.78
Rate for Payer: Hamaspik Choice Inc Medicare	$28.78

ALLODERM CONTOUR MED THIN

Facility OP

$57.56

Service Code	HCPCS Q4116
Hospital Charge Code	64905426
Hospital Revenue Code	636
Min. Negotiated Rate	$20.15
Max. Negotiated Rate	$37.41
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$31.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$21.47
Rate for Payer: Aetna Government	$21.47
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$28.78
Rate for Payer: Cigna LocalPlus Benefit Plan	$33.10
Rate for Payer: Group Health Inc Commercial	$28.78
Rate for Payer: Group Health Inc Medicare	$20.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$28.78
Rate for Payer: Hamaspik Choice Inc Medicare	$28.78
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$37.41

ALLODERM CONT'R THICK MED

Facility IP

$98.01

Service Code	HCPCS Q4116
Hospital Charge Code	64905948
Hospital Revenue Code	636
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$49.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$49.00
Rate for Payer: Hamaspik Choice Inc Medicare	$49.00

ALLODERM CONT'R THICK MED

Facility OP

$98.01

Service Code	HCPCS Q4116
Hospital Charge Code	64905948
Hospital Revenue Code	636
Min. Negotiated Rate	$21.47
Max. Negotiated Rate	$63.71
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$53.91
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$21.47
Rate for Payer: Aetna Government	$21.47
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$49.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$56.36
Rate for Payer: Group Health Inc Commercial	$49.00
Rate for Payer: Group Health Inc Medicare	$34.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$49.00
Rate for Payer: Hamaspik Choice Inc Medicare	$49.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$63.71

ALLODERM CONT'R THICK MED 132CM

Facility OP

$97.67

Service Code	HCPCS Q4116
Hospital Charge Code	64905954
Hospital Revenue Code	636
Min. Negotiated Rate	$21.47
Max. Negotiated Rate	$63.49
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$53.72
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$21.47
Rate for Payer: Aetna Government	$21.47
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$48.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$56.16
Rate for Payer: Group Health Inc Commercial	$48.84
Rate for Payer: Group Health Inc Medicare	$34.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$48.84
Rate for Payer: Hamaspik Choice Inc Medicare	$48.84
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$63.49

ALLODERM CONT'R THICK MED 132CM

Facility IP

$97.67

Service Code	HCPCS Q4116
Hospital Charge Code	64905954
Hospital Revenue Code	636
Min. Negotiated Rate	$48.84
Max. Negotiated Rate	$48.84
Rate for Payer: Hamaspik Choice Inc Medicaid	$48.84
Rate for Payer: Hamaspik Choice Inc Medicare	$48.84

ALLODERM CONT'R THICK SMALL 77CM

Facility IP

$97.69

Service Code	HCPCS Q4116
Hospital Charge Code	64905956
Hospital Revenue Code	636
Min. Negotiated Rate	$48.84
Max. Negotiated Rate	$48.84
Rate for Payer: Hamaspik Choice Inc Medicaid	$48.84
Rate for Payer: Hamaspik Choice Inc Medicare	$48.84

ALLODERM CONT'R THICK SMALL 77CM

Facility OP

$97.69

Service Code	HCPCS Q4116
Hospital Charge Code	64905956
Hospital Revenue Code	636
Min. Negotiated Rate	$21.47
Max. Negotiated Rate	$63.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$53.73
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$21.47
Rate for Payer: Aetna Government	$21.47
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$48.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$56.17
Rate for Payer: Group Health Inc Commercial	$48.84
Rate for Payer: Group Health Inc Medicare	$34.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$48.84
Rate for Payer: Hamaspik Choice Inc Medicare	$48.84
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$63.50

ALLODERM REGEN TIS MATRIX 4X7THN

Facility IP

$41.29

Service Code	HCPCS Q4116
Hospital Charge Code	40205394
Hospital Revenue Code	636
Min. Negotiated Rate	$20.64
Max. Negotiated Rate	$20.64
Rate for Payer: Hamaspik Choice Inc Medicaid	$20.64
Rate for Payer: Hamaspik Choice Inc Medicare	$20.64

ALLODERM REGEN TIS MATRIX 4X7THN

Facility OP

$41.29

Service Code	HCPCS Q4116
Hospital Charge Code	40205394
Hospital Revenue Code	636
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$26.84
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$22.71
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$21.47
Rate for Payer: Aetna Government	$21.47
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$20.64
Rate for Payer: Cigna LocalPlus Benefit Plan	$23.74
Rate for Payer: Group Health Inc Commercial	$20.64
Rate for Payer: Group Health Inc Medicare	$14.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$20.64
Rate for Payer: Hamaspik Choice Inc Medicare	$20.64
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$26.84

ALLODERM REGEN TISSUE MATRIX 3X7

Facility IP

$47.62

Service Code	HCPCS Q4116
Hospital Charge Code	40201100
Hospital Revenue Code	636
Min. Negotiated Rate	$23.81
Max. Negotiated Rate	$23.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$23.81
Rate for Payer: Hamaspik Choice Inc Medicare	$23.81

ALLODERM REGEN TISSUE MATRIX 3X7

Facility OP

$47.62

Service Code	HCPCS Q4116
Hospital Charge Code	40201100
Hospital Revenue Code	636
Min. Negotiated Rate	$16.67
Max. Negotiated Rate	$30.95
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$26.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$21.47
Rate for Payer: Aetna Government	$21.47
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$23.81
Rate for Payer: Cigna LocalPlus Benefit Plan	$27.38
Rate for Payer: Group Health Inc Commercial	$23.81
Rate for Payer: Group Health Inc Medicare	$16.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$23.81
Rate for Payer: Hamaspik Choice Inc Medicare	$23.81
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$30.95

ALLODERM REGEN TISSUE MATRIX 4X7

Facility OP

$66.79

Service Code	HCPCS Q4116
Hospital Charge Code	40201101
Hospital Revenue Code	636
Min. Negotiated Rate	$21.47
Max. Negotiated Rate	$43.41
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$36.73
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$21.47
Rate for Payer: Aetna Government	$21.47
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$33.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$38.40
Rate for Payer: Group Health Inc Commercial	$33.40
Rate for Payer: Group Health Inc Medicare	$23.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$33.40
Rate for Payer: Hamaspik Choice Inc Medicare	$33.40
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$43.41

ALLODERM REGEN TISSUE MATRIX 4X7

Facility IP

$66.79

Service Code	HCPCS Q4116
Hospital Charge Code	40201101
Hospital Revenue Code	636
Min. Negotiated Rate	$33.40
Max. Negotiated Rate	$33.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$33.40
Rate for Payer: Hamaspik Choice Inc Medicare	$33.40

ALLODERM REGEN TISSUE MATRIX 8X16

Facility IP

$228.12

Service Code	HCPCS Q4116
Hospital Charge Code	40204560
Hospital Revenue Code	636
Min. Negotiated Rate	$114.06
Max. Negotiated Rate	$114.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$114.06
Rate for Payer: Hamaspik Choice Inc Medicare	$114.06

ALLODERM REGEN TISSUE MATRIX 8X16

Facility OP

$228.12

Service Code	HCPCS Q4116
Hospital Charge Code	40204560
Hospital Revenue Code	636
Min. Negotiated Rate	$21.47
Max. Negotiated Rate	$148.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$125.47
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$21.47
Rate for Payer: Aetna Government	$21.47
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$114.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$131.17
Rate for Payer: Group Health Inc Commercial	$114.06
Rate for Payer: Group Health Inc Medicare	$79.84
Rate for Payer: Hamaspik Choice Inc Medicaid	$114.06
Rate for Payer: Hamaspik Choice Inc Medicare	$114.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$148.28

ALLODERM (RTU) 8CM X 16CM - THIN

Facility OP

$101.74

Service Code	HCPCS Q4116
Hospital Charge Code	64903652
Hospital Revenue Code	636
Min. Negotiated Rate	$21.47
Max. Negotiated Rate	$66.13
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$55.96
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$21.47
Rate for Payer: Aetna Government	$21.47
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$50.87
Rate for Payer: Cigna LocalPlus Benefit Plan	$58.50
Rate for Payer: Group Health Inc Commercial	$50.87
Rate for Payer: Group Health Inc Medicare	$35.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$50.87
Rate for Payer: Hamaspik Choice Inc Medicare	$50.87
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$66.13

ALLODERM (RTU) 8CM X 16CM - THIN

Facility IP

$101.74

Service Code	HCPCS Q4116
Hospital Charge Code	64903652
Hospital Revenue Code	636
Min. Negotiated Rate	$50.87
Max. Negotiated Rate	$50.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$50.87
Rate for Payer: Hamaspik Choice Inc Medicare	$50.87

ALLODERM RTU 8 X 16 THICK

Facility IP

$102.32

Service Code	HCPCS Q4116
Hospital Charge Code	64903241
Hospital Revenue Code	636
Min. Negotiated Rate	$51.16
Max. Negotiated Rate	$51.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$51.16
Rate for Payer: Hamaspik Choice Inc Medicare	$51.16

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