Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

AMPICILLIN SODIUM 2 G IJ SOLR (WRAPPED)

Facility

OP

$8.53

Service Code	HCPCS J0290
Hospital Charge Code	7248542201
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$6.83
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.69
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Brighton Health Commercial	$6.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.83
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.80
Rate for Payer: EmblemHealth Commercial	$4.27
Rate for Payer: Group Health Inc Commercial	$4.27
Rate for Payer: Group Health Inc Medicare	$2.99
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.27
Rate for Payer: Hamaspik Choice Inc Medicare	$4.27
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.55
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.55

AMPICILLIN SODIUM 2 G IJ SOLR (WRAPPED)

Facility

OP

$34.75

Service Code	HCPCS J0290
Hospital Charge Code	0781341392
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$27.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$19.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Brighton Health Commercial	$26.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$27.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$23.63
Rate for Payer: EmblemHealth Commercial	$17.37
Rate for Payer: Group Health Inc Commercial	$17.37
Rate for Payer: Group Health Inc Medicare	$12.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$17.37
Rate for Payer: Hamaspik Choice Inc Medicare	$17.37
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.55
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$22.59

AMPICILLIN SODIUM 2 G IJ SOLR (WRAPPED)

Facility

OP

$15.92

Service Code	HCPCS J0290
Hospital Charge Code	5515011420
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$12.73
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Brighton Health Commercial	$11.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.73
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.82
Rate for Payer: EmblemHealth Commercial	$7.96
Rate for Payer: Group Health Inc Commercial	$7.96
Rate for Payer: Group Health Inc Medicare	$5.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.96
Rate for Payer: Hamaspik Choice Inc Medicare	$7.96
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.55
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10.34

AMPICILLIN SODIUM 500 MG IJ SOLR

Facility

IP

$4.41

Service Code	HCPCS J0290
Hospital Charge Code	0781925095
Hospital Revenue Code	250
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$2.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.20

AMPICILLIN SODIUM 500 MG IJ SOLR

Facility

IP

$4.41

Service Code	HCPCS J0290
Hospital Charge Code	0781340795
Hospital Revenue Code	250
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$2.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.20

AMPICILLIN SODIUM 500 MG IJ SOLR

Facility

IP

$2.76

Service Code	HCPCS J0290
Hospital Charge Code	7059408501
Hospital Revenue Code	250
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$1.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.38

AMPICILLIN SODIUM 500 MG IJ SOLR

Facility

IP

$2.76

Service Code	HCPCS J0290
Hospital Charge Code	7059408502
Hospital Revenue Code	250
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$1.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.38

AMPICILLIN SODIUM 500 MG IJ SOLR

Facility

OP

$2.76

Service Code	HCPCS J0290
Hospital Charge Code	7059408501
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$2.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.52
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Brighton Health Commercial	$2.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.88
Rate for Payer: EmblemHealth Commercial	$1.38
Rate for Payer: Group Health Inc Commercial	$1.38
Rate for Payer: Group Health Inc Medicare	$0.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.38
Rate for Payer: Hamaspik Choice Inc Medicare	$1.38
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.55
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.79

AMPICILLIN SODIUM 500 MG IJ SOLR

Facility

OP

$2.76

Service Code	HCPCS J0290
Hospital Charge Code	7059408502
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$2.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.52
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Brighton Health Commercial	$2.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.88
Rate for Payer: EmblemHealth Commercial	$1.38
Rate for Payer: Group Health Inc Commercial	$1.38
Rate for Payer: Group Health Inc Medicare	$0.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.38
Rate for Payer: Hamaspik Choice Inc Medicare	$1.38
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.55
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.79

AMPICILLIN SODIUM 500 MG IJ SOLR

Facility

OP

$4.41

Service Code	HCPCS J0290
Hospital Charge Code	0781925095
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$3.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.42
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Brighton Health Commercial	$3.30
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.00
Rate for Payer: EmblemHealth Commercial	$2.20
Rate for Payer: Group Health Inc Commercial	$2.20
Rate for Payer: Group Health Inc Medicare	$1.54
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.20
Rate for Payer: Hamaspik Choice Inc Medicare	$2.20
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.55
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.86

AMPICILLIN SODIUM 500 MG IJ SOLR

Facility

OP

$4.41

Service Code	HCPCS J0290
Hospital Charge Code	0781340795
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$3.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.42
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Brighton Health Commercial	$3.30
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.00
Rate for Payer: EmblemHealth Commercial	$2.20
Rate for Payer: Group Health Inc Commercial	$2.20
Rate for Payer: Group Health Inc Medicare	$1.54
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.20
Rate for Payer: Hamaspik Choice Inc Medicare	$2.20
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.55
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.86

AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR

Facility

IP

$7.74

Service Code	HCPCS J0295
Hospital Charge Code	5515011620
Hospital Revenue Code	250
Min. Negotiated Rate	$3.87
Max. Negotiated Rate	$3.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.87

AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR

Facility

OP

$9.25

Service Code	HCPCS J0295
Hospital Charge Code	0049001383
Hospital Revenue Code	250
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$7.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5.09
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.21
Rate for Payer: Aetna Government	$2.21
Rate for Payer: Brighton Health Commercial	$6.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.29
Rate for Payer: EmblemHealth Commercial	$4.63
Rate for Payer: Group Health Inc Commercial	$4.63
Rate for Payer: Group Health Inc Medicare	$3.24
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.63
Rate for Payer: Hamaspik Choice Inc Medicare	$4.63
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$6.02

AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR

Facility

OP

$9.25

Service Code	HCPCS J0295
Hospital Charge Code	0049001381
Hospital Revenue Code	250
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$7.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5.09
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.21
Rate for Payer: Aetna Government	$2.21
Rate for Payer: Brighton Health Commercial	$6.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.29
Rate for Payer: EmblemHealth Commercial	$4.62
Rate for Payer: Group Health Inc Commercial	$4.62
Rate for Payer: Group Health Inc Medicare	$3.24
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.62
Rate for Payer: Hamaspik Choice Inc Medicare	$4.62
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$6.01

AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR

Facility

IP

$9.25

Service Code	HCPCS J0295
Hospital Charge Code	0049001381
Hospital Revenue Code	250
Min. Negotiated Rate	$4.62
Max. Negotiated Rate	$4.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.62

AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR

Facility

IP

$9.25

Service Code	HCPCS J0295
Hospital Charge Code	0049001383
Hospital Revenue Code	250
Min. Negotiated Rate	$4.63
Max. Negotiated Rate	$4.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.63

AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR

Facility

OP

$7.74

Service Code	HCPCS J0295
Hospital Charge Code	5515011620
Hospital Revenue Code	250
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$6.19
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.21
Rate for Payer: Aetna Government	$2.21
Rate for Payer: Brighton Health Commercial	$5.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.19
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.26
Rate for Payer: EmblemHealth Commercial	$3.87
Rate for Payer: Group Health Inc Commercial	$3.87
Rate for Payer: Group Health Inc Medicare	$2.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.87
Rate for Payer: Hamaspik Choice Inc Medicare	$3.87
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.03

AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IV SOLR

Facility

IP

$6.46

Service Code	NDC 0409268901
Hospital Charge Code	0409268901
Hospital Revenue Code	258
Min. Negotiated Rate	$3.23
Max. Negotiated Rate	$3.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.23

AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IV SOLR

Facility

OP

$6.46

Service Code	NDC 0409268901
Hospital Charge Code	0409268901
Hospital Revenue Code	258
Min. Negotiated Rate	$2.26
Max. Negotiated Rate	$5.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.23
Rate for Payer: Aetna Government	$3.23
Rate for Payer: Brighton Health Commercial	$4.84
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.39
Rate for Payer: EmblemHealth Commercial	$3.23
Rate for Payer: Group Health Inc Commercial	$3.23
Rate for Payer: Group Health Inc Medicare	$2.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.23
Rate for Payer: Hamaspik Choice Inc Medicare	$3.23
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.20

AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR

Facility

IP

$9.14

Service Code	HCPCS J0295
Hospital Charge Code	0641611701
Hospital Revenue Code	250
Min. Negotiated Rate	$4.57
Max. Negotiated Rate	$4.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.57

AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR

Facility

OP

$19.14

Service Code	HCPCS J0295
Hospital Charge Code	4456721110
Hospital Revenue Code	250
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$15.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$10.53
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.21
Rate for Payer: Aetna Government	$2.21
Rate for Payer: Brighton Health Commercial	$14.36
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$15.31
Rate for Payer: Cigna LocalPlus Benefit Plan	$13.02
Rate for Payer: EmblemHealth Commercial	$9.57
Rate for Payer: Group Health Inc Commercial	$9.57
Rate for Payer: Group Health Inc Medicare	$6.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.57
Rate for Payer: Hamaspik Choice Inc Medicare	$9.57
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12.44

AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR

Facility

OP

$14.60

Service Code	HCPCS J0295
Hospital Charge Code	5515011720
Hospital Revenue Code	250
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$11.68
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.21
Rate for Payer: Aetna Government	$2.21
Rate for Payer: Brighton Health Commercial	$10.95
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.68
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.93
Rate for Payer: EmblemHealth Commercial	$7.30
Rate for Payer: Group Health Inc Commercial	$7.30
Rate for Payer: Group Health Inc Medicare	$5.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.30
Rate for Payer: Hamaspik Choice Inc Medicare	$7.30
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.49

AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR

Facility

OP

$6.36

Service Code	HCPCS J0295
Hospital Charge Code	7248541701
Hospital Revenue Code	250
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$5.09
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.21
Rate for Payer: Aetna Government	$2.21
Rate for Payer: Brighton Health Commercial	$4.77
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.09
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.32
Rate for Payer: EmblemHealth Commercial	$3.18
Rate for Payer: Group Health Inc Commercial	$3.18
Rate for Payer: Group Health Inc Medicare	$2.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.18
Rate for Payer: Hamaspik Choice Inc Medicare	$3.18
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.13

AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR

Facility

IP

$14.60

Service Code	HCPCS J0295
Hospital Charge Code	5515011710
Hospital Revenue Code	250
Min. Negotiated Rate	$7.30
Max. Negotiated Rate	$7.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.30

AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR

Facility

IP

$17.47

Service Code	HCPCS J0295
Hospital Charge Code	0049001483
Hospital Revenue Code	250
Min. Negotiated Rate	$8.74
Max. Negotiated Rate	$8.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.74

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