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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

Dexamethasone Bill only

Facility

IP

$132.00

Service Code	HCPCS 80299
Hospital Charge Code	3552990
Hospital Revenue Code	300
Min. Negotiated Rate	$118.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: UnitedHealthcare Commercial	$125.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dexamethasone Ophth 0.1% Sol [HMC]

Facility

IP

$107.32

Service Code	NDC 24208072002
Hospital Charge Code	3805179
Hospital Revenue Code	250
Min. Negotiated Rate	$96.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$96.59
Rate for Payer: UnitedHealthcare Commercial	$101.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dexamethasone Ophth 0.1% Sol [HMC]

Facility

OP

$107.32

Service Code	NDC 24208072002
Hospital Charge Code	3805179
Hospital Revenue Code	250
Min. Negotiated Rate	$42.93
Max. Negotiated Rate	$101.95
Rate for Payer: Aetna Commercial	$96.59
Rate for Payer: Humana Medicare Advantage	$45.07
Rate for Payer: UnitedHealthcare Commercial	$101.95
Rate for Payer: UnitedHealthcare Medicaid	$42.93
Rate for Payer: WPPA Medicare Advantage	$64.39

dexmedetomidine 100 mcg/mL IV Sol [HMC]

Facility

IP

$39.51

Service Code	NDC 42023014625
Hospital Charge Code	3170193
Hospital Revenue Code	250
Min. Negotiated Rate	$35.56
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.56
Rate for Payer: UnitedHealthcare Commercial	$37.53
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dexmedetomidine 100 mcg/mL IV Sol [HMC]

Facility

IP

$45.74

Service Code	NDC 66794023342
Hospital Charge Code	3170193
Hospital Revenue Code	250
Min. Negotiated Rate	$41.17
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$41.17
Rate for Payer: UnitedHealthcare Commercial	$43.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dexmedetomidine 100 mcg/mL IV Sol [HMC]

Facility

OP

$54.36

Service Code	NDC 16729023993
Hospital Charge Code	3170193
Hospital Revenue Code	250
Min. Negotiated Rate	$21.74
Max. Negotiated Rate	$51.64
Rate for Payer: Aetna Commercial	$48.92
Rate for Payer: Humana Medicare Advantage	$22.83
Rate for Payer: UnitedHealthcare Commercial	$51.64
Rate for Payer: UnitedHealthcare Medicaid	$21.74
Rate for Payer: WPPA Medicare Advantage	$32.62

dexmedetomidine 100 mcg/mL IV Sol [HMC]

Facility

OP

$45.74

Service Code	NDC 66794023342
Hospital Charge Code	3170193
Hospital Revenue Code	250
Min. Negotiated Rate	$18.30
Max. Negotiated Rate	$43.45
Rate for Payer: Aetna Commercial	$41.17
Rate for Payer: Humana Medicare Advantage	$19.21
Rate for Payer: UnitedHealthcare Commercial	$43.45
Rate for Payer: UnitedHealthcare Medicaid	$18.30
Rate for Payer: WPPA Medicare Advantage	$27.44

dexmedetomidine 100 mcg/mL IV Sol [HMC]

Facility

IP

$45.92

Service Code	NDC 55150020902
Hospital Charge Code	3170193
Hospital Revenue Code	250
Min. Negotiated Rate	$41.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$41.33
Rate for Payer: UnitedHealthcare Commercial	$43.62
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dexmedetomidine 100 mcg/mL IV Sol [HMC]

Facility

IP

$54.36

Service Code	NDC 16729023993
Hospital Charge Code	3170193
Hospital Revenue Code	250
Min. Negotiated Rate	$48.92
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.92
Rate for Payer: UnitedHealthcare Commercial	$51.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dexmedetomidine 100 mcg/mL IV Sol [HMC]

Facility

OP

$45.92

Service Code	NDC 55150020902
Hospital Charge Code	3170193
Hospital Revenue Code	250
Min. Negotiated Rate	$18.37
Max. Negotiated Rate	$43.62
Rate for Payer: Aetna Commercial	$41.33
Rate for Payer: Humana Medicare Advantage	$19.29
Rate for Payer: UnitedHealthcare Commercial	$43.62
Rate for Payer: UnitedHealthcare Medicaid	$18.37
Rate for Payer: WPPA Medicare Advantage	$27.55

dexmedetomidine 100 mcg/mL IV Sol [HMC]

Facility

OP

$91.28

Service Code	NDC 63323042102
Hospital Charge Code	3170193
Hospital Revenue Code	250
Min. Negotiated Rate	$36.51
Max. Negotiated Rate	$86.72
Rate for Payer: Aetna Commercial	$82.15
Rate for Payer: Humana Medicare Advantage	$38.34
Rate for Payer: UnitedHealthcare Commercial	$86.72
Rate for Payer: UnitedHealthcare Medicaid	$36.51
Rate for Payer: WPPA Medicare Advantage	$54.77

dexmedetomidine 100 mcg/mL IV Sol [HMC]

Facility

OP

$39.51

Service Code	NDC 42023014625
Hospital Charge Code	3170193
Hospital Revenue Code	250
Min. Negotiated Rate	$15.80
Max. Negotiated Rate	$37.53
Rate for Payer: Aetna Commercial	$35.56
Rate for Payer: Humana Medicare Advantage	$16.59
Rate for Payer: UnitedHealthcare Commercial	$37.53
Rate for Payer: UnitedHealthcare Medicaid	$15.80
Rate for Payer: WPPA Medicare Advantage	$23.71

dexmedetomidine 100 mcg/mL IV Sol [HMC]

Facility

IP

$91.28

Service Code	NDC 63323042102
Hospital Charge Code	3170193
Hospital Revenue Code	250
Min. Negotiated Rate	$82.15
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$82.15
Rate for Payer: UnitedHealthcare Commercial	$86.72
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dexmedetomidine 100 mcg/mL IV Sol [HMC]

Facility

OP

$41.60

Service Code	NDC 00409163802
Hospital Charge Code	3170193
Hospital Revenue Code	250
Min. Negotiated Rate	$16.64
Max. Negotiated Rate	$39.52
Rate for Payer: Aetna Commercial	$37.44
Rate for Payer: Humana Medicare Advantage	$17.47
Rate for Payer: UnitedHealthcare Commercial	$39.52
Rate for Payer: UnitedHealthcare Medicaid	$16.64
Rate for Payer: WPPA Medicare Advantage	$24.96

dexmedetomidine 100 mcg/mL IV Sol [HMC]

Facility

IP

$41.60

Service Code	NDC 00409163802
Hospital Charge Code	3170193
Hospital Revenue Code	250
Min. Negotiated Rate	$37.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$37.44
Rate for Payer: UnitedHealthcare Commercial	$39.52
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dextromethorphan-guaiFENesin 10 mg-100 mg/5 mL Oral Liq 5 mL [HMC]

Facility

OP

$13.60

Service Code	NDC 00121063805
Hospital Charge Code	3805554
Hospital Revenue Code	250
Min. Negotiated Rate	$5.44
Max. Negotiated Rate	$12.92
Rate for Payer: Aetna Commercial	$12.24
Rate for Payer: Humana Medicare Advantage	$5.71
Rate for Payer: UnitedHealthcare Commercial	$12.92
Rate for Payer: UnitedHealthcare Medicaid	$5.44
Rate for Payer: WPPA Medicare Advantage	$8.16

dextromethorphan-guaiFENesin 10 mg-100 mg/5 mL Oral Liq 5 mL [HMC]

Facility

IP

$13.60

Service Code	NDC 00121063805
Hospital Charge Code	3805554
Hospital Revenue Code	250
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.24
Rate for Payer: UnitedHealthcare Commercial	$12.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dextromethorphan-guaifenesin 10 mg-200 mg/5 mL Liq [HMC]

Facility

IP

$0.74

Service Code	NDC 60569006404
Hospital Charge Code	38092296
Hospital Revenue Code	257
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$0.67
Rate for Payer: UnitedHealthcare Commercial	$0.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dextromethorphan-guaifenesin 10 mg-200 mg/5 mL Liq [HMC]

Facility

OP

$0.74

Service Code	NDC 60569006404
Hospital Charge Code	38092296
Hospital Revenue Code	257
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.70
Rate for Payer: Aetna Commercial	$0.67
Rate for Payer: Humana Medicare Advantage	$0.31
Rate for Payer: UnitedHealthcare Commercial	$0.70
Rate for Payer: UnitedHealthcare Medicaid	$0.30
Rate for Payer: WPPA Medicare Advantage	$0.44

dextromethorphan-guaifenesin 20 mg-200 mg/10 mL [HMC]

Facility

OP

$10.34

Service Code	NDC 00904675920
Hospital Charge Code	3800779
Hospital Revenue Code	250
Min. Negotiated Rate	$4.14
Max. Negotiated Rate	$9.82
Rate for Payer: Aetna Commercial	$9.31
Rate for Payer: Humana Medicare Advantage	$4.34
Rate for Payer: UnitedHealthcare Commercial	$9.82
Rate for Payer: UnitedHealthcare Medicaid	$4.14
Rate for Payer: WPPA Medicare Advantage	$6.20

dextromethorphan-guaifenesin 20 mg-200 mg/10 mL [HMC]

Facility

IP

$10.34

Service Code	NDC 00904675920
Hospital Charge Code	3800779
Hospital Revenue Code	250
Min. Negotiated Rate	$9.31
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.31
Rate for Payer: UnitedHealthcare Commercial	$9.82
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dextromethorphan-guaifenesin 20mg-400 mg/10 mL Liq 10 mL [HMC]

Facility

OP

$20.84

Service Code	NDC 60569006408
Hospital Charge Code	3800730
Hospital Revenue Code	250
Min. Negotiated Rate	$8.34
Max. Negotiated Rate	$19.80
Rate for Payer: Aetna Commercial	$18.76
Rate for Payer: Humana Medicare Advantage	$8.75
Rate for Payer: UnitedHealthcare Commercial	$19.80
Rate for Payer: UnitedHealthcare Medicaid	$8.34
Rate for Payer: WPPA Medicare Advantage	$12.50

dextromethorphan-guaifenesin 20mg-400 mg/10 mL Liq 10 mL [HMC]

Facility

IP

$20.84

Service Code	NDC 60569006408
Hospital Charge Code	3800730
Hospital Revenue Code	250
Min. Negotiated Rate	$18.76
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.76
Rate for Payer: UnitedHealthcare Commercial	$19.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dextromethorphan-guaiFENesin 30 mg-600 mg ER Tab [HMC]

Facility

OP

$8.15

Service Code	NDC 63824005634
Hospital Charge Code	3800951
Hospital Revenue Code	250
Min. Negotiated Rate	$3.26
Max. Negotiated Rate	$7.74
Rate for Payer: Aetna Commercial	$7.33
Rate for Payer: Humana Medicare Advantage	$3.42
Rate for Payer: UnitedHealthcare Commercial	$7.74
Rate for Payer: UnitedHealthcare Medicaid	$3.26
Rate for Payer: WPPA Medicare Advantage	$4.89

dextromethorphan-guaiFENesin 30 mg-600 mg ER Tab [HMC]

Facility

IP

$8.15

Service Code	NDC 63824005634
Hospital Charge Code	3800951
Hospital Revenue Code	250
Min. Negotiated Rate	$7.33
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.33
Rate for Payer: UnitedHealthcare Commercial	$7.74
Rate for Payer: WPPA Medicare Advantage	$1,200.00

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