St. Barnabas Hospital

All Charges

Charge

Type

Price

AMPICILLIN 500 MG INJ

Facility OP

$1.95

Service Code	HCPCS J0290
Hospital Charge Code	41653354
Hospital Revenue Code	636
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$1.27
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.07
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	$0.98
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.12
Rate for Payer: Fidelis CHP/HARP/Medicaid	$0.70
Rate for Payer: Group Health Inc Commercial	$0.98
Rate for Payer: Group Health Inc Medicare	$0.68
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.98
Rate for Payer: Hamaspik Choice Inc Medicare	$0.98
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	$1.27

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 50MG/ML SUSP

Facility OP

$0.11

Hospital Charge Code	41644269
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.09
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.06
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.06
Rate for Payer: Aetna Government	$0.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.09
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.07
Rate for Payer: Group Health Inc Commercial	$0.06
Rate for Payer: Group Health Inc Medicare	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.06
Rate for Payer: Hamaspik Choice Inc Medicare	$0.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.07

AMPICILLIN 50MG/ML SUSP

Facility OP

$0.11

Hospital Charge Code	41654269
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.09
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.06
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.06
Rate for Payer: Aetna Government	$0.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.09
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.07
Rate for Payer: Group Health Inc Commercial	$0.06
Rate for Payer: Group Health Inc Medicare	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.06
Rate for Payer: Hamaspik Choice Inc Medicare	$0.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.07

AMPICILLIN + SULBACTAM 1500 MG INJ

Facility OP

$3.24

Service Code	HCPCS J0295
Hospital Charge Code	41650085
Hospital Revenue Code	636
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$2.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.78
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.21
Rate for Payer: Aetna Government	$2.21
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.86
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1.70
Rate for Payer: Group Health Inc Commercial	$1.62
Rate for Payer: Group Health Inc Medicare	$1.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.62
Rate for Payer: Hamaspik Choice Inc Medicare	$1.62
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.89
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2.25
Rate for Payer: SOMOS Essential	$2.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.11

AMPICILLIN + SULBACTAM 1500 MG INJ

Facility IP

$3.24

Service Code	HCPCS J0295
Hospital Charge Code	41650085
Hospital Revenue Code	636
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$1.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.62
Rate for Payer: Hamaspik Choice Inc Medicare	$1.62

AMPICILLIN + SULBACTAM 1500 MG INJ

Facility IP

$3.24

Service Code	HCPCS J0295
Hospital Charge Code	41640085
Hospital Revenue Code	636
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$1.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.62
Rate for Payer: Hamaspik Choice Inc Medicare	$1.62

AMPICILLIN + SULBACTAM 1500 MG INJ

Facility OP

$3.24

Service Code	HCPCS J0295
Hospital Charge Code	41640085
Hospital Revenue Code	636
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$2.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.78
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.21
Rate for Payer: Aetna Government	$2.21
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.86
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1.70
Rate for Payer: Group Health Inc Commercial	$1.62
Rate for Payer: Group Health Inc Medicare	$1.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.62
Rate for Payer: Hamaspik Choice Inc Medicare	$1.62
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.89
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2.25
Rate for Payer: SOMOS Essential	$2.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.11

AMPICILLIN + SULBACTAM 1500 MG INJ PEDIA

Facility OP

$7.00

Service Code	HCPCS J0295
Hospital Charge Code	41655502
Hospital Revenue Code	636
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$4.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.21
Rate for Payer: Aetna Government	$2.21
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.02
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1.70
Rate for Payer: Group Health Inc Commercial	$3.50
Rate for Payer: Group Health Inc Medicare	$2.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.89
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2.25
Rate for Payer: SOMOS Essential	$2.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.55

AMPICILLIN + SULBACTAM 1500 MG INJ PEDIA

Facility OP

$7.00

Service Code	HCPCS J0295
Hospital Charge Code	41645502
Hospital Revenue Code	636
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$4.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.21
Rate for Payer: Aetna Government	$2.21
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.02
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1.70
Rate for Payer: Group Health Inc Commercial	$3.50
Rate for Payer: Group Health Inc Medicare	$2.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.89
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2.25
Rate for Payer: SOMOS Essential	$2.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.55

AMPICILLIN + SULBACTAM 1500 MG INJ PEDIA

Facility IP

$7.00

Service Code	HCPCS J0295
Hospital Charge Code	41645502
Hospital Revenue Code	636
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$3.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3.50

AMPICILLIN + SULBACTAM 1500 MG INJ PEDIA

Facility IP

$7.00

Service Code	HCPCS J0295
Hospital Charge Code	41655502
Hospital Revenue Code	636
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$3.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.50
Rate for Payer: Hamaspik Choice Inc Medicare	$3.50

AMPICILLIN + SULBACTAM 3000 MG IN

Facility OP

$28.00

Service Code	HCPCS J0295
Hospital Charge Code	41650066
Hospital Revenue Code	636
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$18.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$15.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.21
Rate for Payer: Aetna Government	$2.21
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$14.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$16.10
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1.70
Rate for Payer: Group Health Inc Commercial	$14.00
Rate for Payer: Group Health Inc Medicare	$9.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$14.00
Rate for Payer: Hamaspik Choice Inc Medicare	$14.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.89
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2.25
Rate for Payer: SOMOS Essential	$2.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$18.20

AMPICILLIN + SULBACTAM 3000 MG IN

Facility IP

$28.00

Service Code	HCPCS J0295
Hospital Charge Code	41650066
Hospital Revenue Code	636
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$14.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$14.00
Rate for Payer: Hamaspik Choice Inc Medicare	$14.00

AMPICILLIN + SULBACTAM 3000 MG INJ

Facility IP

$2.89

Service Code	HCPCS J0295
Hospital Charge Code	41644309
Hospital Revenue Code	636
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$1.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.44
Rate for Payer: Hamaspik Choice Inc Medicare	$1.44

AMPICILLIN + SULBACTAM 3000 MG INJ

Facility OP

$2.89

Service Code	HCPCS J0295
Hospital Charge Code	41644309
Hospital Revenue Code	636
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$2.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.59
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.21
Rate for Payer: Aetna Government	$2.21
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.66
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1.70
Rate for Payer: Group Health Inc Commercial	$1.44
Rate for Payer: Group Health Inc Medicare	$1.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.44
Rate for Payer: Hamaspik Choice Inc Medicare	$1.44
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.89
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2.25
Rate for Payer: SOMOS Essential	$2.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.88

AMPICILLIN + SULBACTAM 3000 MG INJ

Facility OP

$2.89

Service Code	HCPCS J0295
Hospital Charge Code	41654309
Hospital Revenue Code	636
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$2.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.59
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.21
Rate for Payer: Aetna Government	$2.21
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.66
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1.70
Rate for Payer: Group Health Inc Commercial	$1.44
Rate for Payer: Group Health Inc Medicare	$1.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.44
Rate for Payer: Hamaspik Choice Inc Medicare	$1.44
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.89
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2.25
Rate for Payer: SOMOS Essential	$2.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.88

AMPICILLIN + SULBACTAM 3000 MG INJ

Facility IP

$2.89

Service Code	HCPCS J0295
Hospital Charge Code	41654309
Hospital Revenue Code	636
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$1.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.44
Rate for Payer: Hamaspik Choice Inc Medicare	$1.44

AMPICILLIN + SULBACTAM 3000 MG INJ PEDIA

Facility IP

$28.00

Service Code	HCPCS J0295
Hospital Charge Code	41640066
Hospital Revenue Code	636
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$14.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$14.00
Rate for Payer: Hamaspik Choice Inc Medicare	$14.00

AMPICILLIN + SULBACTAM 3000 MG INJ PEDIA

Facility OP

$28.00

Service Code	HCPCS J0295
Hospital Charge Code	41640066
Hospital Revenue Code	636
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$18.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$15.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.21
Rate for Payer: Aetna Government	$2.21
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$14.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$16.10
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1.70
Rate for Payer: Group Health Inc Commercial	$14.00
Rate for Payer: Group Health Inc Medicare	$9.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$14.00
Rate for Payer: Hamaspik Choice Inc Medicare	$14.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.89
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2.25
Rate for Payer: SOMOS Essential	$2.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$18.20

AMPICILLIN-SULBACTAM 30MG IN NS

Facility OP

$0.70

Service Code	HCPCS J0295
Hospital Charge Code	41640272
Hospital Revenue Code	636
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$2.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.21
Rate for Payer: Aetna Government	$2.21
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.40
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1.70
Rate for Payer: Group Health Inc Commercial	$0.35
Rate for Payer: Group Health Inc Medicare	$0.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.35
Rate for Payer: Hamaspik Choice Inc Medicare	$0.35
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.89
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2.25
Rate for Payer: SOMOS Essential	$2.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.46

AMPICILLIN-SULBACTAM 30MG IN NS

Facility IP

$0.70

Service Code	HCPCS J0295
Hospital Charge Code	41640272
Hospital Revenue Code	636
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.35
Rate for Payer: Hamaspik Choice Inc Medicare	$0.35

AMPICILLIN-SULBACTAM 30MG IN NS

Facility OP

$0.70

Service Code	HCPCS J0295
Hospital Charge Code	41650272
Hospital Revenue Code	636
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$2.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.21
Rate for Payer: Aetna Government	$2.21
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.40
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1.70
Rate for Payer: Group Health Inc Commercial	$0.35
Rate for Payer: Group Health Inc Medicare	$0.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.35
Rate for Payer: Hamaspik Choice Inc Medicare	$0.35
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1.89
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2.25
Rate for Payer: SOMOS Essential	$2.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.46

AMPICILLIN-SULBACTAM 30MG IN NS

Facility IP

$0.70

Service Code	HCPCS J0295
Hospital Charge Code	41650272
Hospital Revenue Code	636
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.35
Rate for Payer: Hamaspik Choice Inc Medicare	$0.35

AMPLATZ GRADUATED DILTOR KIT

Facility OP

$582.90

Hospital Charge Code	64905384
Hospital Revenue Code	270
Min. Negotiated Rate	$204.02
Max. Negotiated Rate	$466.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$320.60
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$291.45
Rate for Payer: Aetna Government	$291.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$466.32
Rate for Payer: Cigna LocalPlus Benefit Plan	$396.37
Rate for Payer: Group Health Inc Commercial	$291.45
Rate for Payer: Group Health Inc Medicare	$204.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$291.45
Rate for Payer: Hamaspik Choice Inc Medicare	$291.45

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