St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

DOPAMINE-DEXTROSE 3.2-5 MG/ML-% IV SOLN

Facility

$0.10

Service Code	HCPCS J1265
Hospital Charge Code	0409781022
Hospital Revenue Code	258
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.83
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.79
Rate for Payer: Aetna Government	$0.79
Rate for Payer: Brighton Health Commercial	$0.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.08
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.07
Rate for Payer: EmblemHealth Commercial	$0.05
Rate for Payer: Group Health Inc Commercial	$0.05
Rate for Payer: Group Health Inc Medicare	$0.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.05
Rate for Payer: Hamaspik Choice Inc Medicare	$0.05
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.83
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.06

DOPAMINE-DEXTROSE 3.2-5 MG/ML-% IV SOLN

Facility

$0.10

Service Code	HCPCS J1265
Hospital Charge Code	0338100902
Hospital Revenue Code	258
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.05

DOPAMINE-DEXTROSE 3.2-5 MG/ML-% IV SOLN

Facility

$0.10

Service Code	HCPCS J1265
Hospital Charge Code	0338100902
Hospital Revenue Code	258
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.83
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.79
Rate for Payer: Aetna Government	$0.79
Rate for Payer: Brighton Health Commercial	$0.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.08
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.06
Rate for Payer: EmblemHealth Commercial	$0.05
Rate for Payer: Group Health Inc Commercial	$0.05
Rate for Payer: Group Health Inc Medicare	$0.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.05
Rate for Payer: Hamaspik Choice Inc Medicare	$0.05
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.83
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.06

DOPAMINE HCL 40 MG/ML IV SOLN

Facility

$0.91

Service Code	HCPCS J1265
Hospital Charge Code	0409582011
Hospital Revenue Code	258
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.83
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.79
Rate for Payer: Aetna Government	$0.79
Rate for Payer: Brighton Health Commercial	$0.69
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.73
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.62
Rate for Payer: EmblemHealth Commercial	$0.46
Rate for Payer: Group Health Inc Commercial	$0.46
Rate for Payer: Group Health Inc Medicare	$0.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.46
Rate for Payer: Hamaspik Choice Inc Medicare	$0.46
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.83
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.59

DOPAMINE HCL 40 MG/ML IV SOLN

Facility

$0.70

Service Code	HCPCS J1265
Hospital Charge Code	0143925225
Hospital Revenue Code	258
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.83
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.79
Rate for Payer: Aetna Government	$0.79
Rate for Payer: Brighton Health Commercial	$0.53
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.48
Rate for Payer: EmblemHealth Commercial	$0.35
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	$0.83
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.46

DOPAMINE HCL 40 MG/ML IV SOLN

Facility

$0.91

Service Code	HCPCS J1265
Hospital Charge Code	0409582011
Hospital Revenue Code	258
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.46
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.46

DOPAMINE HCL 40 MG/ML IV SOLN

Facility

$0.70

Service Code	HCPCS J1265
Hospital Charge Code	0143925225
Hospital Revenue Code	258
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.35

DORAVIRINE 100 MG PO TABS

Facility

$70.43

Service Code	NDC 0006306901
Hospital Charge Code	0006306901
Hospital Revenue Code	250
Min. Negotiated Rate	$24.65
Max. Negotiated Rate	$56.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$38.74
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.21
Rate for Payer: Aetna Government	$35.21
Rate for Payer: Brighton Health Commercial	$52.82
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$56.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$47.89
Rate for Payer: EmblemHealth Commercial	$35.21
Rate for Payer: Group Health Inc Commercial	$35.21
Rate for Payer: Group Health Inc Medicare	$24.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.21
Rate for Payer: Hamaspik Choice Inc Medicare	$35.21
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$45.78

DORAVIRINE 100 MG PO TABS

Facility

$70.43

Service Code	NDC 0006306901
Hospital Charge Code	0006306901
Hospital Revenue Code	250
Min. Negotiated Rate	$35.21
Max. Negotiated Rate	$35.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.21

DORNASE ALFA 2.5 MG/2.5ML IN SOLN

Facility

$62.34

Service Code	HCPCS J7639
Hospital Charge Code	5024210039
Hospital Revenue Code	250
Min. Negotiated Rate	$21.82
Max. Negotiated Rate	$55.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$34.29
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$47.80
Rate for Payer: Aetna Government	$47.80
Rate for Payer: Brighton Health Commercial	$46.76
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$49.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$42.39
Rate for Payer: EmblemHealth Commercial	$31.17
Rate for Payer: Group Health Inc Commercial	$31.17
Rate for Payer: Group Health Inc Medicare	$21.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$31.17
Rate for Payer: Hamaspik Choice Inc Medicare	$31.17
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$55.16
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$40.52

DORNASE ALFA 2.5 MG/2.5ML IN SOLN

Facility

$62.34

Service Code	HCPCS J7639
Hospital Charge Code	5024210040
Hospital Revenue Code	250
Min. Negotiated Rate	$21.82
Max. Negotiated Rate	$55.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$34.29
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$47.80
Rate for Payer: Aetna Government	$47.80
Rate for Payer: Brighton Health Commercial	$46.76
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$49.87
Rate for Payer: Cigna LocalPlus Benefit Plan	$42.39
Rate for Payer: EmblemHealth Commercial	$31.17
Rate for Payer: Group Health Inc Commercial	$31.17
Rate for Payer: Group Health Inc Medicare	$21.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$31.17
Rate for Payer: Hamaspik Choice Inc Medicare	$31.17
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$55.16
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$40.52

DORNASE ALFA 2.5 MG/2.5ML IN SOLN

Facility

$62.34

Service Code	HCPCS J7639
Hospital Charge Code	5024210040
Hospital Revenue Code	250
Min. Negotiated Rate	$31.17
Max. Negotiated Rate	$31.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$31.17

DORNASE ALFA 2.5 MG/2.5ML IN SOLN

Facility

$62.34

Service Code	HCPCS J7639
Hospital Charge Code	5024210039
Hospital Revenue Code	250
Min. Negotiated Rate	$31.17
Max. Negotiated Rate	$31.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$31.17

Dorsal & lumbar fusion proc except for curvature of back

Facility

$85,941.59

Service Code	APR-DRG 3041
Min. Negotiated Rate	$34,725.00
Max. Negotiated Rate	$85,941.59
Rate for Payer: Affinity Essential Plan 1&2	$85,941.59
Rate for Payer: Affinity Essential Plan 3&4	$85,941.59
Rate for Payer: Affinity Medicaid/CHP/HARP	$38,196.26
Rate for Payer: Amida Care Medicaid	$38,196.26
Rate for Payer: EmblemHealth Essential Plan 1&2	$85,941.59
Rate for Payer: EmblemHealth Essential Plan 3&4	$38,196.26
Rate for Payer: Fidelis CHP/HARP/Medicaid	$38,196.26
Rate for Payer: Fidelis Qualified Health Plan	$45,835.51
Rate for Payer: Hamaspik Choice Inc Medicaid	$38,196.26
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$38,196.26
Rate for Payer: Healthfirst Commercial	$57,533.00
Rate for Payer: Healthfirst Essential Plan	$85,941.59
Rate for Payer: Healthfirst QHP	$34,725.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$38,196.26
Rate for Payer: SOMOS Essential	$85,941.59
Rate for Payer: United Healthcare Essential Plan 1&2	$85,941.59
Rate for Payer: United Healthcare Essential Plan 3&4	$85,941.59
Rate for Payer: United Healthcare Medicaid	$38,196.26
Rate for Payer: Wellcare CHP/FHP/Medicaid	$38,196.26

Dorsal & lumbar fusion proc except for curvature of back

Facility

$97,702.31

Service Code	APR-DRG 3042
Min. Negotiated Rate	$41,306.00
Max. Negotiated Rate	$97,702.31
Rate for Payer: Affinity Essential Plan 1&2	$97,702.31
Rate for Payer: Affinity Essential Plan 3&4	$97,702.31
Rate for Payer: Affinity Medicaid/CHP/HARP	$43,423.25
Rate for Payer: Amida Care Medicaid	$43,423.25
Rate for Payer: EmblemHealth Essential Plan 1&2	$97,702.31
Rate for Payer: EmblemHealth Essential Plan 3&4	$43,423.25
Rate for Payer: Fidelis CHP/HARP/Medicaid	$43,423.25
Rate for Payer: Fidelis Qualified Health Plan	$52,107.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$43,423.25
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$43,423.25
Rate for Payer: Healthfirst Commercial	$68,861.00
Rate for Payer: Healthfirst Essential Plan	$97,702.31
Rate for Payer: Healthfirst QHP	$41,306.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$43,423.25
Rate for Payer: SOMOS Essential	$97,702.31
Rate for Payer: United Healthcare Essential Plan 1&2	$97,702.31
Rate for Payer: United Healthcare Essential Plan 3&4	$97,702.31
Rate for Payer: United Healthcare Medicaid	$43,423.25
Rate for Payer: Wellcare CHP/FHP/Medicaid	$43,423.25

Dorsal & lumbar fusion proc except for curvature of back

Facility

$125,715.62

Service Code	APR-DRG 3043
Min. Negotiated Rate	$55,873.61
Max. Negotiated Rate	$125,715.62
Rate for Payer: Affinity Essential Plan 1&2	$125,715.62
Rate for Payer: Affinity Essential Plan 3&4	$125,715.62
Rate for Payer: Affinity Medicaid/CHP/HARP	$55,873.61
Rate for Payer: Amida Care Medicaid	$55,873.61
Rate for Payer: EmblemHealth Essential Plan 1&2	$125,715.62
Rate for Payer: EmblemHealth Essential Plan 3&4	$55,873.61
Rate for Payer: Fidelis CHP/HARP/Medicaid	$55,873.61
Rate for Payer: Fidelis Qualified Health Plan	$67,048.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$55,873.61
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$55,873.61
Rate for Payer: Healthfirst Commercial	$95,106.00
Rate for Payer: Healthfirst Essential Plan	$125,715.62
Rate for Payer: Healthfirst QHP	$59,751.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$55,873.61
Rate for Payer: SOMOS Essential	$125,715.62
Rate for Payer: United Healthcare Essential Plan 1&2	$125,715.62
Rate for Payer: United Healthcare Essential Plan 3&4	$125,715.62
Rate for Payer: United Healthcare Medicaid	$55,873.61
Rate for Payer: Wellcare CHP/FHP/Medicaid	$55,873.61

Dorsal & lumbar fusion proc except for curvature of back

Facility

$193,508.26

Service Code	APR-DRG 3044
Min. Negotiated Rate	$86,003.67
Max. Negotiated Rate	$193,508.26
Rate for Payer: Affinity Essential Plan 1&2	$193,508.26
Rate for Payer: Affinity Essential Plan 3&4	$193,508.26
Rate for Payer: Affinity Medicaid/CHP/HARP	$86,003.67
Rate for Payer: Amida Care Medicaid	$86,003.67
Rate for Payer: EmblemHealth Essential Plan 1&2	$193,508.26
Rate for Payer: EmblemHealth Essential Plan 3&4	$86,003.67
Rate for Payer: Fidelis CHP/HARP/Medicaid	$86,003.67
Rate for Payer: Fidelis Qualified Health Plan	$103,204.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$86,003.67
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$86,003.67
Rate for Payer: Healthfirst Commercial	$165,461.00
Rate for Payer: Healthfirst Essential Plan	$193,508.26
Rate for Payer: Healthfirst QHP	$104,376.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$86,003.67
Rate for Payer: SOMOS Essential	$193,508.26
Rate for Payer: United Healthcare Essential Plan 1&2	$193,508.26
Rate for Payer: United Healthcare Essential Plan 3&4	$193,508.26
Rate for Payer: United Healthcare Medicaid	$86,003.67
Rate for Payer: Wellcare CHP/FHP/Medicaid	$86,003.67

Dorsal & lumbar fusion proc for curvature of back

Facility

$154,917.86

Service Code	APR-DRG 3033
Min. Negotiated Rate	$68,852.38
Max. Negotiated Rate	$154,917.86
Rate for Payer: Affinity Essential Plan 1&2	$154,917.86
Rate for Payer: Affinity Essential Plan 3&4	$154,917.86
Rate for Payer: Affinity Medicaid/CHP/HARP	$68,852.38
Rate for Payer: Amida Care Medicaid	$68,852.38
Rate for Payer: EmblemHealth Essential Plan 1&2	$154,917.86
Rate for Payer: EmblemHealth Essential Plan 3&4	$68,852.38
Rate for Payer: Fidelis CHP/HARP/Medicaid	$68,852.38
Rate for Payer: Fidelis Qualified Health Plan	$82,622.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$68,852.38
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$68,852.38
Rate for Payer: Healthfirst Commercial	$116,372.00
Rate for Payer: Healthfirst Essential Plan	$154,917.86
Rate for Payer: Healthfirst QHP	$77,320.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$68,852.38
Rate for Payer: SOMOS Essential	$154,917.86
Rate for Payer: United Healthcare Essential Plan 1&2	$154,917.86
Rate for Payer: United Healthcare Essential Plan 3&4	$154,917.86
Rate for Payer: United Healthcare Medicaid	$68,852.38
Rate for Payer: Wellcare CHP/FHP/Medicaid	$68,852.38

Dorsal & lumbar fusion proc for curvature of back

Facility

$125,026.20

Service Code	APR-DRG 3032
Min. Negotiated Rate	$55,567.20
Max. Negotiated Rate	$125,026.20
Rate for Payer: Affinity Essential Plan 1&2	$125,026.20
Rate for Payer: Affinity Essential Plan 3&4	$125,026.20
Rate for Payer: Affinity Medicaid/CHP/HARP	$55,567.20
Rate for Payer: Amida Care Medicaid	$55,567.20
Rate for Payer: EmblemHealth Essential Plan 1&2	$125,026.20
Rate for Payer: EmblemHealth Essential Plan 3&4	$55,567.20
Rate for Payer: Fidelis CHP/HARP/Medicaid	$55,567.20
Rate for Payer: Fidelis Qualified Health Plan	$66,680.64
Rate for Payer: Hamaspik Choice Inc Medicaid	$55,567.20
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$55,567.20
Rate for Payer: Healthfirst Commercial	$87,832.00
Rate for Payer: Healthfirst Essential Plan	$125,026.20
Rate for Payer: Healthfirst QHP	$57,946.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$55,567.20
Rate for Payer: SOMOS Essential	$125,026.20
Rate for Payer: United Healthcare Essential Plan 1&2	$125,026.20
Rate for Payer: United Healthcare Essential Plan 3&4	$125,026.20
Rate for Payer: United Healthcare Medicaid	$55,567.20
Rate for Payer: Wellcare CHP/FHP/Medicaid	$55,567.20

Dorsal & lumbar fusion proc for curvature of back

Facility

$223,623.27

Service Code	APR-DRG 3034
Min. Negotiated Rate	$99,388.12
Max. Negotiated Rate	$223,623.27
Rate for Payer: Affinity Essential Plan 1&2	$223,623.27
Rate for Payer: Affinity Essential Plan 3&4	$223,623.27
Rate for Payer: Affinity Medicaid/CHP/HARP	$99,388.12
Rate for Payer: Amida Care Medicaid	$99,388.12
Rate for Payer: EmblemHealth Essential Plan 1&2	$223,623.27
Rate for Payer: EmblemHealth Essential Plan 3&4	$99,388.12
Rate for Payer: Fidelis CHP/HARP/Medicaid	$99,388.12
Rate for Payer: Fidelis Qualified Health Plan	$119,265.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$99,388.12
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$99,388.12
Rate for Payer: Healthfirst Commercial	$188,109.00
Rate for Payer: Healthfirst Essential Plan	$223,623.27
Rate for Payer: Healthfirst QHP	$125,866.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$99,388.12
Rate for Payer: SOMOS Essential	$223,623.27
Rate for Payer: United Healthcare Essential Plan 1&2	$223,623.27
Rate for Payer: United Healthcare Essential Plan 3&4	$223,623.27
Rate for Payer: United Healthcare Medicaid	$99,388.12
Rate for Payer: Wellcare CHP/FHP/Medicaid	$99,388.12

Dorsal & lumbar fusion proc for curvature of back

Facility

$109,749.74

Service Code	APR-DRG 3031
Min. Negotiated Rate	$48,777.66
Max. Negotiated Rate	$109,749.74
Rate for Payer: Affinity Essential Plan 1&2	$109,749.74
Rate for Payer: Affinity Essential Plan 3&4	$109,749.74
Rate for Payer: Affinity Medicaid/CHP/HARP	$48,777.66
Rate for Payer: Amida Care Medicaid	$48,777.66
Rate for Payer: EmblemHealth Essential Plan 1&2	$109,749.74
Rate for Payer: EmblemHealth Essential Plan 3&4	$48,777.66
Rate for Payer: Fidelis CHP/HARP/Medicaid	$48,777.66
Rate for Payer: Fidelis Qualified Health Plan	$58,533.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$48,777.66
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$48,777.66
Rate for Payer: Healthfirst Commercial	$75,039.00
Rate for Payer: Healthfirst Essential Plan	$109,749.74
Rate for Payer: Healthfirst QHP	$50,242.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$48,777.66
Rate for Payer: SOMOS Essential	$109,749.74
Rate for Payer: United Healthcare Essential Plan 1&2	$109,749.74
Rate for Payer: United Healthcare Essential Plan 3&4	$109,749.74
Rate for Payer: United Healthcare Medicaid	$48,777.66
Rate for Payer: Wellcare CHP/FHP/Medicaid	$48,777.66

DORZOLAMIDE HCL 2 % OP SOLN

Facility

$9.10

Service Code	NDC 7006950101
Hospital Charge Code	7006950101
Hospital Revenue Code	250
Min. Negotiated Rate	$3.18
Max. Negotiated Rate	$7.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.55
Rate for Payer: Aetna Government	$4.55
Rate for Payer: Brighton Health Commercial	$6.82
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.19
Rate for Payer: EmblemHealth Commercial	$4.55
Rate for Payer: Group Health Inc Commercial	$4.55
Rate for Payer: Group Health Inc Medicare	$3.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.55
Rate for Payer: Hamaspik Choice Inc Medicare	$4.55
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.91

DORZOLAMIDE HCL 2 % OP SOLN

Facility

$9.10

Service Code	NDC 7006950101
Hospital Charge Code	7006950101
Hospital Revenue Code	250
Min. Negotiated Rate	$4.55
Max. Negotiated Rate	$4.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.55

DORZOLAMIDE HCL 2 % OP SOLN

Facility

$6.68

Service Code	NDC 5038323210
Hospital Charge Code	5038323210
Hospital Revenue Code	250
Min. Negotiated Rate	$3.34
Max. Negotiated Rate	$3.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.34

DORZOLAMIDE HCL 2 % OP SOLN

Facility

$6.68

Service Code	NDC 5038323210
Hospital Charge Code	5038323210
Hospital Revenue Code	250
Min. Negotiated Rate	$2.34
Max. Negotiated Rate	$5.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.67
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.34
Rate for Payer: Aetna Government	$3.34
Rate for Payer: Brighton Health Commercial	$5.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.54
Rate for Payer: EmblemHealth Commercial	$3.34
Rate for Payer: Group Health Inc Commercial	$3.34
Rate for Payer: Group Health Inc Medicare	$2.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.34
Rate for Payer: Hamaspik Choice Inc Medicare	$3.34
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.34

Know your out-of-pocket cost for care.

All Charges