St. Barnabas Hospital

All Charges

Charge

Type

Price

26MM AND 7MM HEAD

Facility OP

$1,570.00

Service Code	HCPCS C1713
Hospital Charge Code	40209831
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$1,648.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$863.50
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	$785.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$902.75
Rate for Payer: Fidelis Medicare Advantage	$1,648.50
Rate for Payer: Group Health Inc Commercial	$785.00
Rate for Payer: Group Health Inc Medicare	$549.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$785.00
Rate for Payer: Hamaspik Choice Inc Medicare	$785.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1,020.50

2.7X12M LOCKING SCREW 202.212

Facility OP

$255.60

Service Code	HCPCS C1713
Hospital Charge Code	40202754
Hospital Revenue Code	278
Min. Negotiated Rate	$89.46
Max. Negotiated Rate	$268.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$140.58
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	$127.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$146.97
Rate for Payer: Fidelis Medicare Advantage	$268.38
Rate for Payer: Group Health Inc Commercial	$127.80
Rate for Payer: Group Health Inc Medicare	$89.46
Rate for Payer: Hamaspik Choice Inc Medicaid	$127.80
Rate for Payer: Hamaspik Choice Inc Medicare	$127.80
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$166.14

2.7X12M LOCKING SCREW 202.212

Facility IP

$255.60

Service Code	HCPCS C1713
Hospital Charge Code	40202754
Hospital Revenue Code	278
Min. Negotiated Rate	$127.80
Max. Negotiated Rate	$127.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$127.80
Rate for Payer: Hamaspik Choice Inc Medicare	$127.80

2.8 DRILL BIT

Facility OP

$192.60

Hospital Charge Code	40202758
Hospital Revenue Code	272
Min. Negotiated Rate	$67.41
Max. Negotiated Rate	$154.08
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$105.93
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$96.30
Rate for Payer: Aetna Government	$96.30
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$154.08
Rate for Payer: Cigna LocalPlus Benefit Plan	$130.97
Rate for Payer: Group Health Inc Commercial	$96.30
Rate for Payer: Group Health Inc Medicare	$67.41
Rate for Payer: Hamaspik Choice Inc Medicaid	$96.30
Rate for Payer: Hamaspik Choice Inc Medicare	$96.30

2X2H 3D PLATE MDFC MALLEABLE

Facility IP

$296.00

Service Code	HCPCS C1713
Hospital Charge Code	40200588
Hospital Revenue Code	278
Min. Negotiated Rate	$148.00
Max. Negotiated Rate	$148.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$148.00
Rate for Payer: Hamaspik Choice Inc Medicare	$148.00

2X2H 3D PLATE MDFC MALLEABLE

Facility OP

$296.00

Service Code	HCPCS C1713
Hospital Charge Code	40200588
Hospital Revenue Code	278
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$310.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$162.80
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	$148.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$170.20
Rate for Payer: Fidelis Medicare Advantage	$310.80
Rate for Payer: Group Health Inc Commercial	$148.00
Rate for Payer: Group Health Inc Medicare	$103.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$148.00
Rate for Payer: Hamaspik Choice Inc Medicare	$148.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$192.40

2X2 H 3D PLATE UPFACE MALLEABLE

Facility IP

$376.00

Service Code	HCPCS C1713
Hospital Charge Code	40200589
Hospital Revenue Code	278
Min. Negotiated Rate	$188.00
Max. Negotiated Rate	$188.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$188.00
Rate for Payer: Hamaspik Choice Inc Medicare	$188.00

2X2 H 3D PLATE UPFACE MALLEABLE

Facility OP

$376.00

Service Code	HCPCS C1713
Hospital Charge Code	40200589
Hospital Revenue Code	278
Min. Negotiated Rate	$131.60
Max. Negotiated Rate	$394.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$206.80
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	$188.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$216.20
Rate for Payer: Fidelis Medicare Advantage	$394.80
Rate for Payer: Group Health Inc Commercial	$188.00
Rate for Payer: Group Health Inc Medicare	$131.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$188.00
Rate for Payer: Hamaspik Choice Inc Medicare	$188.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$244.40

2X2H 3D PLT, MDFACE, LOCK

Facility IP

$822.00

Service Code	HCPCS C1781
Hospital Charge Code	40209814
Hospital Revenue Code	278
Min. Negotiated Rate	$411.00
Max. Negotiated Rate	$411.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$411.00
Rate for Payer: Hamaspik Choice Inc Medicare	$411.00

2X2H 3D PLT, MDFACE, LOCK

Facility OP

$822.00

Service Code	HCPCS C1781
Hospital Charge Code	40209814
Hospital Revenue Code	278
Min. Negotiated Rate	$69.35
Max. Negotiated Rate	$863.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$452.10
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	$411.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$472.65
Rate for Payer: Fidelis Medicare Advantage	$863.10
Rate for Payer: Group Health Inc Commercial	$411.00
Rate for Payer: Group Health Inc Medicare	$287.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$411.00
Rate for Payer: Hamaspik Choice Inc Medicare	$411.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$534.30

2X2H 3D PLT MIDFACE

Facility IP

$822.00

Service Code	HCPCS C1781
Hospital Charge Code	40209815
Hospital Revenue Code	278
Min. Negotiated Rate	$411.00
Max. Negotiated Rate	$411.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$411.00
Rate for Payer: Hamaspik Choice Inc Medicare	$411.00

2X2H 3D PLT MIDFACE

Facility OP

$822.00

Service Code	HCPCS C1781
Hospital Charge Code	40209815
Hospital Revenue Code	278
Min. Negotiated Rate	$69.35
Max. Negotiated Rate	$863.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$452.10
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	$411.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$472.65
Rate for Payer: Fidelis Medicare Advantage	$863.10
Rate for Payer: Group Health Inc Commercial	$411.00
Rate for Payer: Group Health Inc Medicare	$287.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$411.00
Rate for Payer: Hamaspik Choice Inc Medicare	$411.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$534.30

2X2H 3D PLT UPFACE MALLBL

Facility IP

$376.00

Service Code	HCPCS C1713
Hospital Charge Code	40209832
Hospital Revenue Code	278
Min. Negotiated Rate	$188.00
Max. Negotiated Rate	$188.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$188.00
Rate for Payer: Hamaspik Choice Inc Medicare	$188.00

2X2H 3D PLT UPFACE MALLBL

Facility OP

$376.00

Service Code	HCPCS C1713
Hospital Charge Code	40209832
Hospital Revenue Code	278
Min. Negotiated Rate	$131.60
Max. Negotiated Rate	$394.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$206.80
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	$188.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$216.20
Rate for Payer: Fidelis Medicare Advantage	$394.80
Rate for Payer: Group Health Inc Commercial	$188.00
Rate for Payer: Group Health Inc Medicare	$131.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$188.00
Rate for Payer: Hamaspik Choice Inc Medicare	$188.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$244.40

2X2 H 3D PLT UPPERFACE

Facility OP

$350.00

Service Code	HCPCS C1713
Hospital Charge Code	40202321
Hospital Revenue Code	278
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$367.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$192.50
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	$175.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$201.25
Rate for Payer: Fidelis Medicare Advantage	$367.50
Rate for Payer: Group Health Inc Commercial	$175.00
Rate for Payer: Group Health Inc Medicare	$122.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$175.00
Rate for Payer: Hamaspik Choice Inc Medicare	$175.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$227.50

2X2 H 3D PLT UPPERFACE

Facility IP

$350.00

Service Code	HCPCS C1713
Hospital Charge Code	40202321
Hospital Revenue Code	278
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$175.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$175.00
Rate for Payer: Hamaspik Choice Inc Medicare	$175.00

2X2H 3D PLT UPPERFACE

Facility OP

$822.00

Service Code	HCPCS C1781
Hospital Charge Code	40209816
Hospital Revenue Code	278
Min. Negotiated Rate	$69.35
Max. Negotiated Rate	$863.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$452.10
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	$411.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$472.65
Rate for Payer: Fidelis Medicare Advantage	$863.10
Rate for Payer: Group Health Inc Commercial	$411.00
Rate for Payer: Group Health Inc Medicare	$287.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$411.00
Rate for Payer: Hamaspik Choice Inc Medicare	$411.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$534.30

2X2H 3D PLT UPPERFACE

Facility IP

$822.00

Service Code	HCPCS C1781
Hospital Charge Code	40209816
Hospital Revenue Code	278
Min. Negotiated Rate	$411.00
Max. Negotiated Rate	$411.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$411.00
Rate for Payer: Hamaspik Choice Inc Medicare	$411.00

2x3 Bioclusive Dressing

Facility OP

$9.22

Hospital Charge Code	40200005
Hospital Revenue Code	270
Min. Negotiated Rate	$3.23
Max. Negotiated Rate	$7.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.61
Rate for Payer: Aetna Government	$4.61
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.27
Rate for Payer: Group Health Inc Commercial	$4.61
Rate for Payer: Group Health Inc Medicare	$3.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.61
Rate for Payer: Hamaspik Choice Inc Medicare	$4.61

2X6 H 3D PLATE MDFC MALLEABLE

Facility OP

$774.00

Service Code	HCPCS C1713
Hospital Charge Code	40200590
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$812.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$425.70
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	$387.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$445.05
Rate for Payer: Fidelis Medicare Advantage	$812.70
Rate for Payer: Group Health Inc Commercial	$387.00
Rate for Payer: Group Health Inc Medicare	$270.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$387.00
Rate for Payer: Hamaspik Choice Inc Medicare	$387.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$503.10

2X6 H 3D PLATE MDFC MALLEABLE

Facility IP

$774.00

Service Code	HCPCS C1713
Hospital Charge Code	40200590
Hospital Revenue Code	278
Min. Negotiated Rate	$387.00
Max. Negotiated Rate	$387.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$387.00
Rate for Payer: Hamaspik Choice Inc Medicare	$387.00

2X6 H 3D PLT, MDFACE LOCK

Facility OP

$688.00

Service Code	HCPCS C1713
Hospital Charge Code	40202322
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$722.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$378.40
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	$344.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$395.60
Rate for Payer: Fidelis Medicare Advantage	$722.40
Rate for Payer: Group Health Inc Commercial	$344.00
Rate for Payer: Group Health Inc Medicare	$240.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$344.00
Rate for Payer: Hamaspik Choice Inc Medicare	$344.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$447.20

2X6 H 3D PLT, MDFACE LOCK

Facility IP

$688.00

Service Code	HCPCS C1713
Hospital Charge Code	40202322
Hospital Revenue Code	278
Min. Negotiated Rate	$344.00
Max. Negotiated Rate	$344.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$344.00
Rate for Payer: Hamaspik Choice Inc Medicare	$344.00

2X6H 3D PLT,MDFACE,LOCK

Facility OP

$988.00

Service Code	HCPCS C1781
Hospital Charge Code	40209817
Hospital Revenue Code	278
Min. Negotiated Rate	$69.35
Max. Negotiated Rate	$1,037.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$543.40
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	$494.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$568.10
Rate for Payer: Fidelis Medicare Advantage	$1,037.40
Rate for Payer: Group Health Inc Commercial	$494.00
Rate for Payer: Group Health Inc Medicare	$345.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$494.00
Rate for Payer: Hamaspik Choice Inc Medicare	$494.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$642.20

2X6H 3D PLT,MDFACE,LOCK

Facility IP

$988.00

Service Code	HCPCS C1781
Hospital Charge Code	40209817
Hospital Revenue Code	278
Min. Negotiated Rate	$494.00
Max. Negotiated Rate	$494.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$494.00
Rate for Payer: Hamaspik Choice Inc Medicare	$494.00

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