St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

AMPICILLIN SODIUM 1 G IJ SOLR [469]

Facility

$8.64

Service Code	HCPCS J0290
Hospital Charge Code	00781340495
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$6.91
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Brighton Health Commercial	$6.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.91
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.87
Rate for Payer: Group Health Inc Commercial	$4.32
Rate for Payer: Group Health Inc Medicare	$3.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.32
Rate for Payer: Hamaspik Choice Inc Medicare	$4.32
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$1.00
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$1.06
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$1.06
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.61

AMPICILLIN SODIUM 1 G IJ SOLR [469]

Facility

$8.21

Service Code	HCPCS J0290
Hospital Charge Code	55150011310
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$6.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Brighton Health Commercial	$6.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.58
Rate for Payer: Group Health Inc Commercial	$4.10
Rate for Payer: Group Health Inc Medicare	$2.87
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.10
Rate for Payer: Hamaspik Choice Inc Medicare	$4.10
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$1.00
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$1.06
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$1.06
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.33

AMPICILLIN SODIUM 250 MG IJ SOLR [473]

Facility

$4.19

Service Code	HCPCS J0290
Hospital Charge Code	00781340278
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$3.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Brighton Health Commercial	$3.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.85
Rate for Payer: Group Health Inc Commercial	$2.09
Rate for Payer: Group Health Inc Medicare	$1.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.09
Rate for Payer: Hamaspik Choice Inc Medicare	$2.09
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$1.00
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$1.06
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$1.06
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.72

AMPICILLIN SODIUM 250 MG IJ SOLR [473]

Facility

$4.19

Service Code	HCPCS J0290
Hospital Charge Code	00781340295
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$3.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Brighton Health Commercial	$3.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.85
Rate for Payer: Group Health Inc Commercial	$2.09
Rate for Payer: Group Health Inc Medicare	$1.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.09
Rate for Payer: Hamaspik Choice Inc Medicare	$2.09
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$1.00
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$1.06
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$1.06
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.72

AMPICILLIN SODIUM 2 G IJ SOLR (WRAPPED) [401279]

Facility

$16.75

Service Code	HCPCS J0290
Hospital Charge Code	00781340880
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$13.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9.21
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Brighton Health Commercial	$12.56
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$13.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$11.39
Rate for Payer: Group Health Inc Commercial	$8.38
Rate for Payer: Group Health Inc Medicare	$5.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.38
Rate for Payer: Hamaspik Choice Inc Medicare	$8.38
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$1.00
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$1.06
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$1.06
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10.89

AMPICILLIN SODIUM 2 G IJ SOLR (WRAPPED) [401279]

Facility

$15.92

Service Code	HCPCS J0290
Hospital Charge Code	55150011420
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
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: 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: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$1.00
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$1.06
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$1.06
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10.34

AMPICILLIN SODIUM 2 G IJ SOLR (WRAPPED) [401279]

Facility

$34.75

Service Code	HCPCS J0290
Hospital Charge Code	00781341392
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
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: 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: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$1.00
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$1.06
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$1.06
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$22.59

AMPICILLIN SODIUM 500 MG IJ SOLR [474]

Facility

$2.76

Service Code	HCPCS J0290
Hospital Charge Code	70594008501
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
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: 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: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$1.00
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$1.06
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$1.06
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.79

AMPICILLIN SODIUM 500 MG IJ SOLR [474]

Facility

$4.41

Service Code	HCPCS J0290
Hospital Charge Code	00781925095
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
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: 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: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$1.00
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$1.06
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$1.06
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.86

AMPICILLIN SODIUM 500 MG IJ SOLR [474]

Facility

$4.41

Service Code	HCPCS J0290
Hospital Charge Code	00781340795
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
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: 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: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$1.00
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$1.06
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$1.06
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.86

AMPICILLIN SODIUM 500 MG IJ SOLR [474]

Facility

$2.76

Service Code	HCPCS J0290
Hospital Charge Code	70594008502
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
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: 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: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$1.00
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$1.06
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$1.06
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$1.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.79

AMPICILLIN + SULBACTAM 1500 MG INJ

Facility

$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

$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: Brighton Health Commercial	$1.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.86
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: 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

$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

$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: Brighton Health Commercial	$1.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.86
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: 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

$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

$7.00

Service Code	HCPCS J0295
Hospital Charge Code	41645502
Hospital Revenue Code	636
Min. Negotiated Rate	$2.21
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: Brighton Health Commercial	$4.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.02
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: 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

$7.00

Service Code	HCPCS J0295
Hospital Charge Code	41655502
Hospital Revenue Code	636
Min. Negotiated Rate	$2.21
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: Brighton Health Commercial	$4.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.02
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: 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

$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

$28.00

Service Code	HCPCS J0295
Hospital Charge Code	41650066
Hospital Revenue Code	636
Min. Negotiated Rate	$2.21
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: Brighton Health Commercial	$16.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$14.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$16.10
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: 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

$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

$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

$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: Brighton Health Commercial	$1.73
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.66
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: 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

$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: Brighton Health Commercial	$1.73
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.66
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: 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

$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

Know your out-of-pocket cost for care.

All Charges