St. Barnabas Hospital

All Charges

Charge

Type

Price

AMPICILLIN 1000 MG INJ

Facility IP

$2.74

Service Code	HCPCS J0290
Hospital Charge Code	41654180
Hospital Revenue Code	636
Min. Negotiated Rate	$1.37
Max. Negotiated Rate	$1.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.37
Rate for Payer: Hamaspik Choice Inc Medicare	$1.37

AMPICILLIN 125 MG INJ

Facility OP

$32.55

Service Code	HCPCS J0290
Hospital Charge Code	41644267
Hospital Revenue Code	636
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$21.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$17.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$16.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$18.72
Rate for Payer: Fidelis CHP/HARP/Medicaid	$0.70
Rate for Payer: Group Health Inc Commercial	$16.28
Rate for Payer: Group Health Inc Medicare	$11.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.28
Rate for Payer: Hamaspik Choice Inc Medicare	$16.28
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.78
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1.06
Rate for Payer: SOMOS Essential	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$21.16

AMPICILLIN 125 MG INJ

Facility IP

$32.55

Service Code	HCPCS J0290
Hospital Charge Code	41644267
Hospital Revenue Code	636
Min. Negotiated Rate	$16.28
Max. Negotiated Rate	$16.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.28
Rate for Payer: Hamaspik Choice Inc Medicare	$16.28

AMPICILLIN 125 MG INJ

Facility OP

$32.55

Service Code	HCPCS J0290
Hospital Charge Code	41654267
Hospital Revenue Code	636
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$21.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$17.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$16.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$18.72
Rate for Payer: Fidelis CHP/HARP/Medicaid	$0.70
Rate for Payer: Group Health Inc Commercial	$16.28
Rate for Payer: Group Health Inc Medicare	$11.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.28
Rate for Payer: Hamaspik Choice Inc Medicare	$16.28
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.78
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1.06
Rate for Payer: SOMOS Essential	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$21.16

AMPICILLIN 125 MG INJ

Facility IP

$32.55

Service Code	HCPCS J0290
Hospital Charge Code	41654267
Hospital Revenue Code	636
Min. Negotiated Rate	$16.28
Max. Negotiated Rate	$16.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$16.28
Rate for Payer: Hamaspik Choice Inc Medicare	$16.28

AMPICILLIN 2000 MG INJ

Facility IP

$1.74

Service Code	HCPCS J0290
Hospital Charge Code	41644181
Hospital Revenue Code	636
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$0.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.87
Rate for Payer: Hamaspik Choice Inc Medicare	$0.87

AMPICILLIN 2000 MG INJ

Facility OP

$1.74

Service Code	HCPCS J0290
Hospital Charge Code	41654181
Hospital Revenue Code	636
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.13
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.96
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.87
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.00
Rate for Payer: Fidelis CHP/HARP/Medicaid	$0.70
Rate for Payer: Group Health Inc Commercial	$0.87
Rate for Payer: Group Health Inc Medicare	$0.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.87
Rate for Payer: Hamaspik Choice Inc Medicare	$0.87
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.78
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1.06
Rate for Payer: SOMOS Essential	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.13

AMPICILLIN 2000 MG INJ

Facility OP

$1.74

Service Code	HCPCS J0290
Hospital Charge Code	41644181
Hospital Revenue Code	636
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.13
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.96
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.87
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.00
Rate for Payer: Fidelis CHP/HARP/Medicaid	$0.70
Rate for Payer: Group Health Inc Commercial	$0.87
Rate for Payer: Group Health Inc Medicare	$0.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.87
Rate for Payer: Hamaspik Choice Inc Medicare	$0.87
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.78
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1.06
Rate for Payer: SOMOS Essential	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.13

AMPICILLIN 2000 MG INJ

Facility IP

$1.74

Service Code	HCPCS J0290
Hospital Charge Code	41654181
Hospital Revenue Code	636
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$0.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.87
Rate for Payer: Hamaspik Choice Inc Medicare	$0.87

AMPICILLIN 20MG/ML IN NS

Facility IP

$0.66

Service Code	HCPCS J0290
Hospital Charge Code	41640271
Hospital Revenue Code	636
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33

AMPICILLIN 20MG/ML IN NS

Facility OP

$0.66

Service Code	HCPCS J0290
Hospital Charge Code	41640271
Hospital Revenue Code	636
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$1.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.33
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.38
Rate for Payer: Fidelis CHP/HARP/Medicaid	$0.70
Rate for Payer: Group Health Inc Commercial	$0.33
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.78
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1.06
Rate for Payer: SOMOS Essential	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.43

AMPICILLIN 20MG/ML IN NS

Facility IP

$0.66

Service Code	HCPCS J0290
Hospital Charge Code	41650271
Hospital Revenue Code	636
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33

AMPICILLIN 20MG/ML IN NS

Facility OP

$0.66

Service Code	HCPCS J0290
Hospital Charge Code	41650271
Hospital Revenue Code	636
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$1.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.33
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.38
Rate for Payer: Fidelis CHP/HARP/Medicaid	$0.70
Rate for Payer: Group Health Inc Commercial	$0.33
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.78
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1.06
Rate for Payer: SOMOS Essential	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.43

AMPICILLIN 250 MG CAP

Facility OP

$0.25

Hospital Charge Code	41643362
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.17
Rate for Payer: Group Health Inc Commercial	$0.13
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.16

AMPICILLIN 250 MG CAP

Facility OP

$0.25

Hospital Charge Code	41653362
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.17
Rate for Payer: Group Health Inc Commercial	$0.13
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.16

AMPICILLIN 250 MG INJ

Facility IP

$3.14

Service Code	HCPCS J0290
Hospital Charge Code	41654179
Hospital Revenue Code	636
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$1.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.57
Rate for Payer: Hamaspik Choice Inc Medicare	$1.57

AMPICILLIN 250 MG INJ

Facility IP

$3.14

Service Code	HCPCS J0290
Hospital Charge Code	41644179
Hospital Revenue Code	636
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$1.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.57
Rate for Payer: Hamaspik Choice Inc Medicare	$1.57

AMPICILLIN 250 MG INJ

Facility OP

$3.14

Service Code	HCPCS J0290
Hospital Charge Code	41654179
Hospital Revenue Code	636
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$2.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.73
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.81
Rate for Payer: Fidelis CHP/HARP/Medicaid	$0.70
Rate for Payer: Group Health Inc Commercial	$1.57
Rate for Payer: Group Health Inc Medicare	$1.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.57
Rate for Payer: Hamaspik Choice Inc Medicare	$1.57
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.78
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1.06
Rate for Payer: SOMOS Essential	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.04

AMPICILLIN 250 MG INJ

Facility OP

$3.14

Service Code	HCPCS J0290
Hospital Charge Code	41644179
Hospital Revenue Code	636
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$2.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.73
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.81
Rate for Payer: Fidelis CHP/HARP/Medicaid	$0.70
Rate for Payer: Group Health Inc Commercial	$1.57
Rate for Payer: Group Health Inc Medicare	$1.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.57
Rate for Payer: Hamaspik Choice Inc Medicare	$1.57
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.78
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1.06
Rate for Payer: SOMOS Essential	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.04

AMPICILLIN 25 MG/ML SUSP

Facility OP

$0.07

Hospital Charge Code	41655531
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.04
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.05
Rate for Payer: Group Health Inc Commercial	$0.04
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.04
Rate for Payer: Hamaspik Choice Inc Medicare	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.05

AMPICILLIN 25 MG/ML SUSP

Facility OP

$0.07

Hospital Charge Code	41645531
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.04
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.05
Rate for Payer: Group Health Inc Commercial	$0.04
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.04
Rate for Payer: Hamaspik Choice Inc Medicare	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.05

AMPICILLIN 500 MG CAP

Facility OP

$0.45

Hospital Charge Code	41643363
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.36
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.23
Rate for Payer: Aetna Government	$0.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.36
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.31
Rate for Payer: Group Health Inc Commercial	$0.23
Rate for Payer: Group Health Inc Medicare	$0.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.23
Rate for Payer: Hamaspik Choice Inc Medicare	$0.23
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.29

AMPICILLIN 500 MG CAP

Facility OP

$0.45

Hospital Charge Code	41653363
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.36
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.23
Rate for Payer: Aetna Government	$0.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.36
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.31
Rate for Payer: Group Health Inc Commercial	$0.23
Rate for Payer: Group Health Inc Medicare	$0.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.23
Rate for Payer: Hamaspik Choice Inc Medicare	$0.23
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.29

AMPICILLIN 500 MG INJ

Facility IP

$1.95

Service Code	HCPCS J0290
Hospital Charge Code	41653354
Hospital Revenue Code	636
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$0.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.98
Rate for Payer: Hamaspik Choice Inc Medicare	$0.98

AMPICILLIN 500 MG INJ

Facility IP

$1.95

Service Code	HCPCS J0290
Hospital Charge Code	41643354
Hospital Revenue Code	636
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$0.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.98
Rate for Payer: Hamaspik Choice Inc Medicare	$0.98

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