St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ SOLN (WRAPPED) [4081112]

Facility

$6.29

Service Code	HCPCS J1100
Hospital Charge Code	70069002125
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$5.03
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$4.72
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.03
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.28
Rate for Payer: Group Health Inc Commercial	$3.14
Rate for Payer: Group Health Inc Medicare	$2.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.14
Rate for Payer: Hamaspik Choice Inc Medicare	$3.14
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.12
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.12
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.12
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.09

DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ SOLN (WRAPPED) [4081112]

Facility

$1.72

Service Code	HCPCS J1100
Hospital Charge Code	00641036721
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$1.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$1.29
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.17
Rate for Payer: Group Health Inc Commercial	$0.86
Rate for Payer: Group Health Inc Medicare	$0.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.86
Rate for Payer: Hamaspik Choice Inc Medicare	$0.86
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.12
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.12
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.12
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.12

DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML IJ SOLN [124966]

Facility

$0.21

Service Code	HCPCS J1100
Hospital Charge Code	63323016526
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.17
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$0.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.17
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.14
Rate for Payer: Group Health Inc Commercial	$0.11
Rate for Payer: Group Health Inc Medicare	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.11
Rate for Payer: Hamaspik Choice Inc Medicare	$0.11
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.12
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.12
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.12
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.14

DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML IJ SOLN [124966]

Facility

$1.66

Service Code	HCPCS J1100
Hospital Charge Code	63323016505
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$1.33
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.91
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$1.24
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.33
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.13
Rate for Payer: Group Health Inc Commercial	$0.83
Rate for Payer: Group Health Inc Medicare	$0.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.83
Rate for Payer: Hamaspik Choice Inc Medicare	$0.83
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.12
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.12
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.12
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.08

DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML IJ SOLN [124966]

Facility

$0.26

Service Code	HCPCS J1100
Hospital Charge Code	00641614625
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$0.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.18
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: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.12
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.12
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.12
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.17

DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML IJ SOLN [124966]

Facility

$0.47

Service Code	HCPCS J1100
Hospital Charge Code	67457042254
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.37
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$0.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.37
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.32
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: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.12
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.12
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.12
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.30

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN [2332]

Facility

$1.16

Service Code	HCPCS J1100
Hospital Charge Code	00641614501
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.93
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$0.87
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.93
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.79
Rate for Payer: Group Health Inc Commercial	$0.58
Rate for Payer: Group Health Inc Medicare	$0.41
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.58
Rate for Payer: Hamaspik Choice Inc Medicare	$0.58
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.12
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.12
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.12
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.75

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN [2332]

Facility

$1.16

Service Code	HCPCS J1100
Hospital Charge Code	00641614525
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.93
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$0.87
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.93
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.79
Rate for Payer: Group Health Inc Commercial	$0.58
Rate for Payer: Group Health Inc Medicare	$0.41
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.58
Rate for Payer: Hamaspik Choice Inc Medicare	$0.58
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.12
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.12
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.12
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.75

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN [2332]

Facility

$1.63

Service Code	HCPCS J1100
Hospital Charge Code	63323016501
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$1.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$1.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.11
Rate for Payer: Group Health Inc Commercial	$0.81
Rate for Payer: Group Health Inc Medicare	$0.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.81
Rate for Payer: Hamaspik Choice Inc Medicare	$0.81
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.12
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.12
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.12
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.06

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN [2332]

Facility

$3.46

Service Code	HCPCS J1100
Hospital Charge Code	63323016502
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$2.77
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$2.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.77
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.35
Rate for Payer: Group Health Inc Commercial	$1.73
Rate for Payer: Group Health Inc Medicare	$1.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.73
Rate for Payer: Hamaspik Choice Inc Medicare	$1.73
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.12
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.12
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.12
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.25

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN [2332]

Facility

$0.99

Service Code	HCPCS J1100
Hospital Charge Code	67457042312
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.79
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.54
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$0.74
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.79
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.67
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.12
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.12
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.12
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.64

DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN [116345]

Facility

$6.29

Service Code	HCPCS J1100
Hospital Charge Code	70069002101
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$5.03
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$4.72
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.03
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.28
Rate for Payer: Group Health Inc Commercial	$3.14
Rate for Payer: Group Health Inc Medicare	$2.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.14
Rate for Payer: Hamaspik Choice Inc Medicare	$3.14
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.12
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.12
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.12
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.09

DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN [116345]

Facility

$6.29

Service Code	HCPCS J1100
Hospital Charge Code	70069002125
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$5.03
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$4.72
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.03
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.28
Rate for Payer: Group Health Inc Commercial	$3.14
Rate for Payer: Group Health Inc Medicare	$2.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.14
Rate for Payer: Hamaspik Choice Inc Medicare	$3.14
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.12
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.12
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.12
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.09

DEXAMETHASONE SUPP(8AM 4,11PM)

Facility

$40.75

Service Code	HCPCS 82533
Hospital Charge Code	40609844
Hospital Revenue Code	301
Min. Negotiated Rate	$11.41
Max. Negotiated Rate	$30.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$22.41
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.30
Rate for Payer: Aetna Government	$16.30
Rate for Payer: Affinity Essential Plan 1&2	$11.41
Rate for Payer: Affinity Essential Plan 3&4	$11.41
Rate for Payer: Affinity Medicaid/CHP/HARP	$11.41
Rate for Payer: Brighton Health Commercial	$30.56
Rate for Payer: Cash Price	$16.30
Rate for Payer: Cash Price	$16.30
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$16.30
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$25.92
Rate for Payer: Cigna LocalPlus Benefit Plan	$21.93
Rate for Payer: Elderplan Medicare Advantage	$16.30
Rate for Payer: EmblemHealth Commercial	$16.30
Rate for Payer: Fidelis Essential Plan Aliesa	$13.86
Rate for Payer: Fidelis Essential Plan QHP	$14.51
Rate for Payer: Fidelis Medicare Advantage	$16.30
Rate for Payer: Fidelis Qualified Health Plan	$14.51
Rate for Payer: Group Health Inc Commercial	$16.30
Rate for Payer: Group Health Inc Medicare	$16.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$20.38
Rate for Payer: Hamaspik Choice Inc Medicare	$16.30
Rate for Payer: Healthfirst Medicare Advantage	$16.30
Rate for Payer: Healthfirst QHP	$16.30
Rate for Payer: Humana Medicare	$16.63
Rate for Payer: Senior Whole Health Medicare Advantage	$16.30
Rate for Payer: United Healthcare Commercial	$20.66
Rate for Payer: United Healthcare Medicare Advantage	$16.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$16.30
Rate for Payer: Wellcare CHP/FHP/Medicaid	$13.04
Rate for Payer: Wellcare Medicare	$14.67

DEXAMETHASONE SUPP(8AM 4,11PM)

Facility

$40.75

Service Code	HCPCS 82533
Hospital Charge Code	40609844
Hospital Revenue Code	301
Rate for Payer: Cash Price	$16.30

DEXAMETHASONE-TOBRAMYCIN OPHTHALMIC OINT

Facility

$259.00

Hospital Charge Code	41650401
Hospital Revenue Code	250
Min. Negotiated Rate	$90.65
Max. Negotiated Rate	$207.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$142.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$129.50
Rate for Payer: Aetna Government	$129.50
Rate for Payer: Brighton Health Commercial	$194.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$207.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$176.12
Rate for Payer: Group Health Inc Commercial	$129.50
Rate for Payer: Group Health Inc Medicare	$90.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$129.50
Rate for Payer: Hamaspik Choice Inc Medicare	$129.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$168.35

DEXAMETHASONE-TOBRAMYCIN OPHTHALMIC OINT

Facility

$259.00

Hospital Charge Code	41640401
Hospital Revenue Code	250
Min. Negotiated Rate	$90.65
Max. Negotiated Rate	$207.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$142.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$129.50
Rate for Payer: Aetna Government	$129.50
Rate for Payer: Brighton Health Commercial	$194.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$207.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$176.12
Rate for Payer: Group Health Inc Commercial	$129.50
Rate for Payer: Group Health Inc Medicare	$90.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$129.50
Rate for Payer: Hamaspik Choice Inc Medicare	$129.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$168.35

DEXAMETHASONE-TOBRAMYCIN OPHTHALMIC SUSP

Facility

$71.00

Hospital Charge Code	41650337
Hospital Revenue Code	250
Min. Negotiated Rate	$24.85
Max. Negotiated Rate	$56.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$39.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.50
Rate for Payer: Aetna Government	$35.50
Rate for Payer: Brighton Health Commercial	$53.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$56.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$48.28
Rate for Payer: Group Health Inc Commercial	$35.50
Rate for Payer: Group Health Inc Medicare	$24.85
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.50
Rate for Payer: Hamaspik Choice Inc Medicare	$35.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$46.15

DEXAMETHASONE-TOBRAMYCIN OPHTHALMIC SUSP

Facility

$71.00

Hospital Charge Code	41640337
Hospital Revenue Code	250
Min. Negotiated Rate	$24.85
Max. Negotiated Rate	$56.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$39.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.50
Rate for Payer: Aetna Government	$35.50
Rate for Payer: Brighton Health Commercial	$53.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$56.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$48.28
Rate for Payer: Group Health Inc Commercial	$35.50
Rate for Payer: Group Health Inc Medicare	$24.85
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.50
Rate for Payer: Hamaspik Choice Inc Medicare	$35.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$46.15

DEXAMETHSONE 4MG/D5W 50ML

Facility

$0.24

Service Code	HCPCS J1100
Hospital Charge Code	41655885
Hospital Revenue Code	636
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$0.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.14
Rate for Payer: Group Health Inc Commercial	$0.12
Rate for Payer: Group Health Inc Medicare	$0.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.12
Rate for Payer: Hamaspik Choice Inc Medicare	$0.12
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.12
Rate for Payer: SOMOS Essential	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.16

DEXAMETHSONE 4MG/D5W 50ML

Facility

$0.24

Service Code	HCPCS J1100
Hospital Charge Code	41655885
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.12
Rate for Payer: Hamaspik Choice Inc Medicare	$0.12

DEXAMTHASONE .2MG/ML INJ PED 1MG

Facility

$3.00

Service Code	HCPCS J1100
Hospital Charge Code	41647082
Hospital Revenue Code	636
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$1.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1.50

DEXAMTHASONE .2MG/ML INJ PED 1MG

Facility

$3.00

Service Code	HCPCS J1100
Hospital Charge Code	41647082
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$1.95
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$1.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.72
Rate for Payer: Group Health Inc Commercial	$1.50
Rate for Payer: Group Health Inc Medicare	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.12
Rate for Payer: SOMOS Essential	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.95

DEXAMTHOSONE 200MG/5ML INJ -1MG

Facility

$0.01

Service Code	HCPCS J1100
Hospital Charge Code	41648161
Hospital Revenue Code	636
Max. Negotiated Rate	$0.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.12
Rate for Payer: SOMOS Essential	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

DEXAMTHOSONE 200MG/5ML INJ -1MG

Facility

$0.01

Service Code	HCPCS J1100
Hospital Charge Code	41648161
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01

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