St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

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	$73.00
Max. Negotiated Rate	$73.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$73.00

HC ANTIDEP TRICYCLIC/CYCLICALS 6+ DOXEPIN&NORDOX - BUNDLED CHARGE

Facility

$146.00

Service Code	CPT 80337
Hospital Charge Code	3018033704
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+ DOXEPIN&NORDOX - BUNDLED CHARGE

Facility

$146.00

Service Code	CPT 80337
Hospital Charge Code	3018033704
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+ IMIPRAMINE LEVEL - BUNDLED CHARGE

Facility

$146.00

Service Code	CPT 80337
Hospital Charge Code	3018033705
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+ IMIPRAMINE LEVEL - BUNDLED CHARGE

Facility

$146.00

Service Code	CPT 80337
Hospital Charge Code	3018033705
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+ NORTRIPTYLINE LVL - BUNDLED CHARGE

Facility

$146.00

Service Code	CPT 80337
Hospital Charge Code	3018033706
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+ NORTRIPTYLINE LVL - BUNDLED CHARGE

Facility

$146.00

Service Code	CPT 80337
Hospital Charge Code	3018033706
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+ TRICYCLIC ANTIDEP - BUNDLED CHARGE

Facility

$135.00

Service Code	CPT 80337
Hospital Charge Code	3018033701
Hospital Revenue Code	301
Min. Negotiated Rate	$67.50
Max. Negotiated Rate	$67.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$67.50

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

Facility

$135.00

Service Code	CPT 80337
Hospital Charge Code	3018033701
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$108.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$74.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$101.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$108.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$91.80
Rate for Payer: EmblemHealth Commercial	$67.50
Rate for Payer: Group Health Inc Commercial	$67.50
Rate for Payer: Group Health Inc Medicare	$47.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$67.50
Rate for Payer: Hamaspik Choice Inc Medicare	$67.50
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 ANTIEPILEPTICS NOS 1-3 DIMETHADIONE - BUNDLED CHARGE

Facility

$281.00

Service Code	CPT 80339
Hospital Charge Code	3018033903
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$224.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$154.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$210.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$224.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$191.08
Rate for Payer: EmblemHealth Commercial	$140.50
Rate for Payer: Group Health Inc Commercial	$140.50
Rate for Payer: Group Health Inc Medicare	$98.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$140.50
Rate for Payer: Hamaspik Choice Inc Medicare	$140.50
Rate for Payer: United Healthcare Commercial	$18.14

HC ANTIEPILEPTICS NOS 1-3 DIMETHADIONE - BUNDLED CHARGE

Facility

$281.00

Service Code	CPT 80339
Hospital Charge Code	3018033903
Hospital Revenue Code	301
Min. Negotiated Rate	$140.50
Max. Negotiated Rate	$140.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$140.50

HC ANTIEPILEPTICS NOS 1-3 METHSUXIMIDE - BUNDLED CHARGE

Facility

$281.00

Service Code	CPT 80339
Hospital Charge Code	3018033904
Hospital Revenue Code	301
Min. Negotiated Rate	$140.50
Max. Negotiated Rate	$140.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$140.50

HC ANTIEPILEPTICS NOS 1-3 METHSUXIMIDE - BUNDLED CHARGE

Facility

$281.00

Service Code	CPT 80339
Hospital Charge Code	3018033904
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$224.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$154.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$210.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$224.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$191.08
Rate for Payer: EmblemHealth Commercial	$140.50
Rate for Payer: Group Health Inc Commercial	$140.50
Rate for Payer: Group Health Inc Medicare	$98.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$140.50
Rate for Payer: Hamaspik Choice Inc Medicare	$140.50
Rate for Payer: United Healthcare Commercial	$18.14

HC ANTIEPILEPTICS NOS 4-6 DIMETHADIONE - BUNDLED CHARGE

Facility

$562.00

Service Code	CPT 80340
Hospital Charge Code	3018034001
Hospital Revenue Code	301
Min. Negotiated Rate	$281.00
Max. Negotiated Rate	$281.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$281.00

HC ANTIEPILEPTICS NOS 4-6 DIMETHADIONE - BUNDLED CHARGE

Facility

$562.00

Service Code	CPT 80340
Hospital Charge Code	3018034001
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$449.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$309.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$421.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$449.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$382.16
Rate for Payer: EmblemHealth Commercial	$281.00
Rate for Payer: Group Health Inc Commercial	$281.00
Rate for Payer: Group Health Inc Medicare	$196.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$281.00
Rate for Payer: Hamaspik Choice Inc Medicare	$281.00
Rate for Payer: United Healthcare Commercial	$18.14

HC ANTIEPILEPTICS NOS 4-6 METHSUXIMIDE & NORMETH - BUNDLED CHARGE

Facility

$562.00

Service Code	CPT 80340
Hospital Charge Code	3018034002
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$449.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$309.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$421.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$449.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$382.16
Rate for Payer: EmblemHealth Commercial	$281.00
Rate for Payer: Group Health Inc Commercial	$281.00
Rate for Payer: Group Health Inc Medicare	$196.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$281.00
Rate for Payer: Hamaspik Choice Inc Medicare	$281.00
Rate for Payer: United Healthcare Commercial	$18.14

HC ANTIEPILEPTICS NOS 4-6 METHSUXIMIDE & NORMETH - BUNDLED CHARGE

Facility

$562.00

Service Code	CPT 80340
Hospital Charge Code	3018034002
Hospital Revenue Code	301
Min. Negotiated Rate	$281.00
Max. Negotiated Rate	$281.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$281.00

HC ANTIEPILEPTICS NOS 7+ DIMETHADIONE - BUNDLED CHARGE

Facility

$843.00

Service Code	CPT 80341
Hospital Charge Code	3018034101
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$674.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$463.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$632.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$674.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$573.24
Rate for Payer: EmblemHealth Commercial	$421.50
Rate for Payer: Group Health Inc Commercial	$421.50
Rate for Payer: Group Health Inc Medicare	$295.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$421.50
Rate for Payer: Hamaspik Choice Inc Medicare	$421.50
Rate for Payer: United Healthcare Commercial	$18.14

HC ANTIEPILEPTICS NOS 7+ DIMETHADIONE - BUNDLED CHARGE

Facility

$843.00

Service Code	CPT 80341
Hospital Charge Code	3018034101
Hospital Revenue Code	301
Min. Negotiated Rate	$421.50
Max. Negotiated Rate	$421.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$421.50

HC ANTIEPILEPTICS NOS 7+ METHSUXIMIDE & NORMETH - BUNDLED CHARGE

Facility

$843.00

Service Code	CPT 80341
Hospital Charge Code	3018034102
Hospital Revenue Code	301
Min. Negotiated Rate	$421.50
Max. Negotiated Rate	$421.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$421.50

HC ANTIEPILEPTICS NOS 7+ METHSUXIMIDE & NORMETH - BUNDLED CHARGE

Facility

$843.00

Service Code	CPT 80341
Hospital Charge Code	3018034102
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$674.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$463.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$632.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$674.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$573.24
Rate for Payer: EmblemHealth Commercial	$421.50
Rate for Payer: Group Health Inc Commercial	$421.50
Rate for Payer: Group Health Inc Medicare	$295.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$421.50
Rate for Payer: Hamaspik Choice Inc Medicare	$421.50
Rate for Payer: United Healthcare Commercial	$18.14

HC ANTIEPILEPTICS NOT OTHERWISE SPECIFIED 1-3 - LACOSAMIDE

Facility

$281.00

Service Code	CPT 80339
Hospital Charge Code	3018033901
Hospital Revenue Code	301
Min. Negotiated Rate	$140.50
Max. Negotiated Rate	$140.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$140.50

HC ANTIEPILEPTICS NOT OTHERWISE SPECIFIED 1-3 - LACOSAMIDE

Facility

$281.00

Service Code	CPT 80339
Hospital Charge Code	3018033901
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$224.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$154.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$210.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$224.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$191.08
Rate for Payer: EmblemHealth Commercial	$140.50
Rate for Payer: Group Health Inc Commercial	$140.50
Rate for Payer: Group Health Inc Medicare	$98.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$140.50
Rate for Payer: Hamaspik Choice Inc Medicare	$140.50
Rate for Payer: United Healthcare Commercial	$18.14

HC ANTIEPILEPTICS NOT OTHERWISE SPECIFIED 1-3 - RUFINAMIDE

Facility

$281.00

Service Code	CPT 80339
Hospital Charge Code	3018033906
Hospital Revenue Code	301
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$224.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$154.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$210.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$224.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$191.08
Rate for Payer: EmblemHealth Commercial	$140.50
Rate for Payer: Group Health Inc Commercial	$140.50
Rate for Payer: Group Health Inc Medicare	$98.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$140.50
Rate for Payer: Hamaspik Choice Inc Medicare	$140.50
Rate for Payer: United Healthcare Commercial	$18.14

HC ANTIEPILEPTICS NOT OTHERWISE SPECIFIED 1-3 - RUFINAMIDE

Facility

$281.00

Service Code	CPT 80339
Hospital Charge Code	3018033906
Hospital Revenue Code	301
Min. Negotiated Rate	$140.50
Max. Negotiated Rate	$140.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$140.50

Know your out-of-pocket cost for care.

All Charges