St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

HC ANTIDEP TRICYCLIC/CYCLICALS 1-2 DESIPRAMINE LVL - BUNDLED CHARGE

Facility

$36.00

Service Code	CPT 80335
Hospital Charge Code	3018033509
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$28.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$19.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$27.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$28.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$24.48
Rate for Payer: EmblemHealth Commercial	$18.00
Rate for Payer: Group Health Inc Commercial	$18.00
Rate for Payer: Group Health Inc Medicare	$12.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$18.00
Rate for Payer: Hamaspik Choice Inc Medicare	$18.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$5.05
Rate for Payer: Healthfirst Essential Plan	$11.36
Rate for Payer: United Healthcare Commercial	$21.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$5.05

HC ANTIDEP TRICYCLIC/CYCLICALS 1-2 DESIPRAMINE LVL - BUNDLED CHARGE

Facility

$36.00

Service Code	CPT 80335
Hospital Charge Code	3018033509
Hospital Revenue Code	301
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$18.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$18.00

HC ANTIDEP TRICYCLIC/CYCLICALS 1-2 DOXEPIN&NORDOX - BUNDLED CHARGE

Facility

$45.00

Service Code	CPT 80335
Hospital Charge Code	3018033510
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$36.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$24.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$33.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$36.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$30.60
Rate for Payer: EmblemHealth Commercial	$22.50
Rate for Payer: Group Health Inc Commercial	$22.50
Rate for Payer: Group Health Inc Medicare	$15.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.50
Rate for Payer: Hamaspik Choice Inc Medicare	$22.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$5.05
Rate for Payer: Healthfirst Essential Plan	$11.36
Rate for Payer: United Healthcare Commercial	$21.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$5.05

HC ANTIDEP TRICYCLIC/CYCLICALS 1-2 DOXEPIN&NORDOX - BUNDLED CHARGE

Facility

$45.00

Service Code	CPT 80335
Hospital Charge Code	3018033510
Hospital Revenue Code	301
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$22.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.50

HC ANTIDEP TRICYCLIC/CYCLICALS 1-2 IMIPRAMINE LEVEL - BUNDLED CHARGE

Facility

$45.00

Service Code	CPT 80335
Hospital Charge Code	3018033511
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$36.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$24.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$33.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$36.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$30.60
Rate for Payer: EmblemHealth Commercial	$22.50
Rate for Payer: Group Health Inc Commercial	$22.50
Rate for Payer: Group Health Inc Medicare	$15.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.50
Rate for Payer: Hamaspik Choice Inc Medicare	$22.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$5.05
Rate for Payer: Healthfirst Essential Plan	$11.36
Rate for Payer: United Healthcare Commercial	$21.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$5.05

HC ANTIDEP TRICYCLIC/CYCLICALS 1-2 IMIPRAMINE LEVEL - BUNDLED CHARGE

Facility

$45.00

Service Code	CPT 80335
Hospital Charge Code	3018033511
Hospital Revenue Code	301
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$22.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.50

HC ANTIDEP TRICYCLIC/CYCLICALS 1-2 NORTRIPTYLINE LVL - BUNDLED CHARGE

Facility

$45.00

Service Code	CPT 80335
Hospital Charge Code	3018033512
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$36.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$24.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$33.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$36.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$30.60
Rate for Payer: EmblemHealth Commercial	$22.50
Rate for Payer: Group Health Inc Commercial	$22.50
Rate for Payer: Group Health Inc Medicare	$15.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.50
Rate for Payer: Hamaspik Choice Inc Medicare	$22.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$5.05
Rate for Payer: Healthfirst Essential Plan	$11.36
Rate for Payer: United Healthcare Commercial	$21.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$5.05

HC ANTIDEP TRICYCLIC/CYCLICALS 1-2 NORTRIPTYLINE LVL - BUNDLED CHARGE

Facility

$45.00

Service Code	CPT 80335
Hospital Charge Code	3018033512
Hospital Revenue Code	301
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$22.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.50

HC ANTIDEP TRICYCLIC/CYCLICALS 1-2 TRICYCLIC ANTIDEP - BUNDLED CHARGE

Facility

$45.00

Service Code	CPT 80335
Hospital Charge Code	3018033507
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$36.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$24.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$33.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$36.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$30.60
Rate for Payer: EmblemHealth Commercial	$22.50
Rate for Payer: Group Health Inc Commercial	$22.50
Rate for Payer: Group Health Inc Medicare	$15.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.50
Rate for Payer: Hamaspik Choice Inc Medicare	$22.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$5.05
Rate for Payer: Healthfirst Essential Plan	$11.36
Rate for Payer: United Healthcare Commercial	$21.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$5.05

HC ANTIDEP TRICYCLIC/CYCLICALS 1-2 TRICYCLIC ANTIDEP - BUNDLED CHARGE

Facility

$45.00

Service Code	CPT 80335
Hospital Charge Code	3018033507
Hospital Revenue Code	301
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$22.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.50

HC ANTIDEP TRICYCLIC/CYCLICALS 3-5 AMITRIPTYLINE LVL - BUNDLED CHARGE

Facility

$73.00

Service Code	CPT 80336
Hospital Charge Code	3018033602
Hospital Revenue Code	301
Min. Negotiated Rate	$36.50
Max. Negotiated Rate	$36.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.50

HC ANTIDEP TRICYCLIC/CYCLICALS 3-5 AMITRIPTYLINE LVL - BUNDLED CHARGE

Facility

$73.00

Service Code	CPT 80336
Hospital Charge Code	3018033602
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$58.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$40.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$54.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$58.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$49.64
Rate for Payer: EmblemHealth Commercial	$36.50
Rate for Payer: Group Health Inc Commercial	$36.50
Rate for Payer: Group Health Inc Medicare	$25.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.50
Rate for Payer: Hamaspik Choice Inc Medicare	$36.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$5.05
Rate for Payer: Healthfirst Essential Plan	$11.36
Rate for Payer: United Healthcare Commercial	$21.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$5.05

HC ANTIDEP TRICYCLIC/CYCLICALS 3-5 DESIPRAMINE LVL - BUNDLED CHARGE

Facility

$73.00

Service Code	CPT 80336
Hospital Charge Code	3018033603
Hospital Revenue Code	301
Min. Negotiated Rate	$36.50
Max. Negotiated Rate	$36.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.50

HC ANTIDEP TRICYCLIC/CYCLICALS 3-5 DESIPRAMINE LVL - BUNDLED CHARGE

Facility

$73.00

Service Code	CPT 80336
Hospital Charge Code	3018033603
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$58.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$40.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$54.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$58.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$49.64
Rate for Payer: EmblemHealth Commercial	$36.50
Rate for Payer: Group Health Inc Commercial	$36.50
Rate for Payer: Group Health Inc Medicare	$25.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.50
Rate for Payer: Hamaspik Choice Inc Medicare	$36.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$5.05
Rate for Payer: Healthfirst Essential Plan	$11.36
Rate for Payer: United Healthcare Commercial	$21.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$5.05

HC ANTIDEP TRICYCLIC/CYCLICALS 3-5 DOXEPIN&NORDOX - BUNDLED CHARGE

Facility

$73.00

Service Code	CPT 80336
Hospital Charge Code	3018033604
Hospital Revenue Code	301
Min. Negotiated Rate	$36.50
Max. Negotiated Rate	$36.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.50

HC ANTIDEP TRICYCLIC/CYCLICALS 3-5 DOXEPIN&NORDOX - BUNDLED CHARGE

Facility

$73.00

Service Code	CPT 80336
Hospital Charge Code	3018033604
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$58.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$40.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$54.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$58.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$49.64
Rate for Payer: EmblemHealth Commercial	$36.50
Rate for Payer: Group Health Inc Commercial	$36.50
Rate for Payer: Group Health Inc Medicare	$25.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.50
Rate for Payer: Hamaspik Choice Inc Medicare	$36.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$5.05
Rate for Payer: Healthfirst Essential Plan	$11.36
Rate for Payer: United Healthcare Commercial	$21.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$5.05

HC ANTIDEP TRICYCLIC/CYCLICALS 3-5 IMIPRAMINE LEVEL - BUNDLED CHARGE

Facility

$73.00

Service Code	CPT 80336
Hospital Charge Code	3018033605
Hospital Revenue Code	301
Min. Negotiated Rate	$36.50
Max. Negotiated Rate	$36.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.50

HC ANTIDEP TRICYCLIC/CYCLICALS 3-5 IMIPRAMINE LEVEL - BUNDLED CHARGE

Facility

$73.00

Service Code	CPT 80336
Hospital Charge Code	3018033605
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$58.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$40.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$54.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$58.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$49.64
Rate for Payer: EmblemHealth Commercial	$36.50
Rate for Payer: Group Health Inc Commercial	$36.50
Rate for Payer: Group Health Inc Medicare	$25.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.50
Rate for Payer: Hamaspik Choice Inc Medicare	$36.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$5.05
Rate for Payer: Healthfirst Essential Plan	$11.36
Rate for Payer: United Healthcare Commercial	$21.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$5.05

HC ANTIDEP TRICYCLIC/CYCLICALS 3-5 NORTRIPTYLINE LVL - BUNDLED CHARGE

Facility

$73.00

Service Code	CPT 80336
Hospital Charge Code	3018033606
Hospital Revenue Code	301
Min. Negotiated Rate	$36.50
Max. Negotiated Rate	$36.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.50

HC ANTIDEP TRICYCLIC/CYCLICALS 3-5 NORTRIPTYLINE LVL - BUNDLED CHARGE

Facility

$73.00

Service Code	CPT 80336
Hospital Charge Code	3018033606
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$58.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$40.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$54.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$58.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$49.64
Rate for Payer: EmblemHealth Commercial	$36.50
Rate for Payer: Group Health Inc Commercial	$36.50
Rate for Payer: Group Health Inc Medicare	$25.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.50
Rate for Payer: Hamaspik Choice Inc Medicare	$36.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$5.05
Rate for Payer: Healthfirst Essential Plan	$11.36
Rate for Payer: United Healthcare Commercial	$21.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$5.05

HC ANTIDEP TRICYCLIC/CYCLICALS 3-5 TRICYCLIC ANTIDEP - BUNDLED CHARGE

Facility

$90.00

Service Code	CPT 80336
Hospital Charge Code	3018033601
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$72.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$49.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$67.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$72.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$61.20
Rate for Payer: EmblemHealth Commercial	$45.00
Rate for Payer: Group Health Inc Commercial	$45.00
Rate for Payer: Group Health Inc Medicare	$31.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$45.00
Rate for Payer: Hamaspik Choice Inc Medicare	$45.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$5.05
Rate for Payer: Healthfirst Essential Plan	$11.36
Rate for Payer: United Healthcare Commercial	$21.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$5.05

HC ANTIDEP TRICYCLIC/CYCLICALS 3-5 TRICYCLIC ANTIDEP - BUNDLED CHARGE

Facility

$90.00

Service Code	CPT 80336
Hospital Charge Code	3018033601
Hospital Revenue Code	301
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$45.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$45.00

HC ANTIDEP TRICYCLIC/CYCLICALS 6+ AMITRIPTYLINE LVL - BUNDLED CHARGE

Facility

$146.00

Service Code	CPT 80337
Hospital Charge Code	3018033702
Hospital Revenue Code	301
Min. Negotiated Rate	$73.00
Max. Negotiated Rate	$73.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$73.00

HC ANTIDEP TRICYCLIC/CYCLICALS 6+ AMITRIPTYLINE LVL - BUNDLED CHARGE

Facility

$146.00

Service Code	CPT 80337
Hospital Charge Code	3018033702
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$116.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$80.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$109.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$116.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$99.28
Rate for Payer: EmblemHealth Commercial	$73.00
Rate for Payer: Group Health Inc Commercial	$73.00
Rate for Payer: Group Health Inc Medicare	$51.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$73.00
Rate for Payer: Hamaspik Choice Inc Medicare	$73.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$5.05
Rate for Payer: Healthfirst Essential Plan	$11.36
Rate for Payer: United Healthcare Commercial	$21.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$5.05

HC ANTIDEP TRICYCLIC/CYCLICALS 6+ DESIPRAMINE LVL - BUNDLED CHARGE

Facility

$146.00

Service Code	CPT 80337
Hospital Charge Code	3018033703
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$116.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$80.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$109.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$116.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$99.28
Rate for Payer: EmblemHealth Commercial	$73.00
Rate for Payer: Group Health Inc Commercial	$73.00
Rate for Payer: Group Health Inc Medicare	$51.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$73.00
Rate for Payer: Hamaspik Choice Inc Medicare	$73.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$5.05
Rate for Payer: Healthfirst Essential Plan	$11.36
Rate for Payer: United Healthcare Commercial	$21.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$5.05

Know your out-of-pocket cost for care.

All Charges