Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

PROMETHAZINE 12.5 MG SUPP

Facility

$118.66

Service Code	NDC 713053612
Hospital Charge Code	60627859
Hospital Revenue Code	250
Min. Negotiated Rate	$17.80
Max. Negotiated Rate	$17.80
Rate for Payer: Qualcare PPO/HMO/WC	$17.80

PROMETHAZINE 12.5MG TAB

Facility

$4.00

Service Code	HCPCS Q0169
Hospital Charge Code	6063943163
Hospital Revenue Code	636
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.97
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.97
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

PROMETHAZINE 12.5MG TAB

Facility

$4.00

Service Code	HCPCS Q0169
Hospital Charge Code	6063943163
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.52
Rate for Payer: Aetna Medicare Advantage	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.02
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.97
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Community & State	$0.10
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

PROMETHAZINE/25MG/1ML

Facility

$7.00

Hospital Charge Code	60633757
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$3.50
Rate for Payer: Aetna Commercial	$2.66
Rate for Payer: Aetna Medicare Advantage	$2.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.78
Rate for Payer: Cigna Commercial	$3.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.10
Rate for Payer: Oxford Commercial	$1.40
Rate for Payer: Qualcare PPO/HMO/WC	$1.05
Rate for Payer: UnitedHealthcare Commercial	$1.40
Rate for Payer: UnitedHealthcare Community & State	$0.17
Rate for Payer: Wellpoint Medicaid Managed Care	$0.19

PROMETHAZINE/25MG/1ML

Facility

$7.00

Hospital Charge Code	60633757
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.05
Rate for Payer: Qualcare PPO/HMO/WC	$1.05

PROMETHAZINE 25 MG/ML INJ

Facility

$6.77

Service Code	HCPCS J2550
Hospital Charge Code	6023402
Hospital Revenue Code	636
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.64
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.64
Rate for Payer: Qualcare PPO/HMO/WC	$1.02

PROMETHAZINE 25 MG/ML INJ

Facility

$6.77

Service Code	HCPCS J2550
Hospital Charge Code	6023402
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$3.38
Rate for Payer: Aetna Commercial	$2.57
Rate for Payer: Aetna Medicare Advantage	$2.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.73
Rate for Payer: Cigna Commercial	$3.38
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.64
Rate for Payer: Qualcare PPO/HMO/WC	$1.02
Rate for Payer: UnitedHealthcare Community & State	$0.16
Rate for Payer: Wellpoint Medicaid Managed Care	$0.18

PROMETHAZINE 25 MG SUPP

Facility

$118.66

Service Code	NDC 45802075930
Hospital Charge Code	60627860
Hospital Revenue Code	250
Min. Negotiated Rate	$2.86
Max. Negotiated Rate	$59.33
Rate for Payer: Aetna Commercial	$45.09
Rate for Payer: Aetna Medicare Advantage	$35.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$30.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$30.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$30.26
Rate for Payer: Cigna Commercial	$59.33
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$35.60
Rate for Payer: Oxford Commercial	$23.73
Rate for Payer: Qualcare PPO/HMO/WC	$17.80
Rate for Payer: UnitedHealthcare Commercial	$23.73
Rate for Payer: UnitedHealthcare Community & State	$2.86
Rate for Payer: Wellpoint Medicaid Managed Care	$3.14

PROMETHAZINE 25 MG SUPP

Facility

$118.66

Service Code	NDC 45802075930
Hospital Charge Code	60627860
Hospital Revenue Code	250
Min. Negotiated Rate	$17.80
Max. Negotiated Rate	$17.80
Rate for Payer: Qualcare PPO/HMO/WC	$17.80

PROMETHAZINE 25 MG TAB

Facility

$4.00

Service Code	HCPCS Q0169
Hospital Charge Code	60629866
Hospital Revenue Code	636
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.97
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.97
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

PROMETHAZINE 25 MG TAB

Facility

$4.00

Service Code	HCPCS Q0169
Hospital Charge Code	60629866
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.52
Rate for Payer: Aetna Medicare Advantage	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.02
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.97
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Community & State	$0.10
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

PROMETHAZINE/50MG/1ML

Facility

$7.00

Hospital Charge Code	60633758
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.05
Rate for Payer: Qualcare PPO/HMO/WC	$1.05

PROMETHAZINE/50MG/1ML

Facility

$7.00

Hospital Charge Code	60633758
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$3.50
Rate for Payer: Aetna Commercial	$2.66
Rate for Payer: Aetna Medicare Advantage	$2.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.78
Rate for Payer: Cigna Commercial	$3.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.10
Rate for Payer: Oxford Commercial	$1.40
Rate for Payer: Qualcare PPO/HMO/WC	$1.05
Rate for Payer: UnitedHealthcare Commercial	$1.40
Rate for Payer: UnitedHealthcare Community & State	$0.17
Rate for Payer: Wellpoint Medicaid Managed Care	$0.19

PROMETHAZINE 50 MG/ML INJ

Facility

$14.87

Service Code	HCPCS J2550
Hospital Charge Code	6014195
Hospital Revenue Code	636
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$3.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.60
Rate for Payer: Qualcare PPO/HMO/WC	$2.23

PROMETHAZINE 50 MG/ML INJ

Facility

$14.87

Service Code	HCPCS J2550
Hospital Charge Code	6014195
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$7.43
Rate for Payer: Aetna Commercial	$5.65
Rate for Payer: Aetna Medicare Advantage	$4.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.79
Rate for Payer: Cigna Commercial	$7.43
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.60
Rate for Payer: Qualcare PPO/HMO/WC	$2.23
Rate for Payer: UnitedHealthcare Community & State	$0.36
Rate for Payer: Wellpoint Medicaid Managed Care	$0.39

PROMETHAZINE 6.25MG

Facility

$88.80

Hospital Charge Code	60635758
Hospital Revenue Code	250
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$13.32
Rate for Payer: Qualcare PPO/HMO/WC	$13.32

PROMETHAZINE 6.25MG

Facility

$88.80

Hospital Charge Code	60635758
Hospital Revenue Code	250
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$44.40
Rate for Payer: Aetna Commercial	$33.74
Rate for Payer: Aetna Medicare Advantage	$26.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$22.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$22.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$22.64
Rate for Payer: Cigna Commercial	$44.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$26.64
Rate for Payer: Oxford Commercial	$17.76
Rate for Payer: Qualcare PPO/HMO/WC	$13.32
Rate for Payer: UnitedHealthcare Commercial	$17.76
Rate for Payer: UnitedHealthcare Community & State	$2.14
Rate for Payer: Wellpoint Medicaid Managed Care	$2.35

PROMETHAZINE 6.25MG/5ML

Facility

$1.00

Hospital Charge Code	60635689
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna Commercial	$0.38
Rate for Payer: Aetna Medicare Advantage	$0.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.26
Rate for Payer: Cigna Commercial	$0.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.30
Rate for Payer: Oxford Commercial	$0.20
Rate for Payer: Qualcare PPO/HMO/WC	$0.15
Rate for Payer: UnitedHealthcare Commercial	$0.20
Rate for Payer: UnitedHealthcare Community & State	$0.02
Rate for Payer: Wellpoint Medicaid Managed Care	$0.03

PROMETHAZINE 6.25MG/5ML

Facility

$1.00

Hospital Charge Code	60635689
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: Qualcare PPO/HMO/WC	$0.15

PROMETHAZINE/6.25MG/5ML

Facility

$15.00

Hospital Charge Code	60633759
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: Aetna Medicare Advantage	$4.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.83
Rate for Payer: Cigna Commercial	$7.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.50
Rate for Payer: Oxford Commercial	$3.00
Rate for Payer: Qualcare PPO/HMO/WC	$2.25
Rate for Payer: UnitedHealthcare Commercial	$3.00
Rate for Payer: UnitedHealthcare Community & State	$0.36
Rate for Payer: Wellpoint Medicaid Managed Care	$0.40

PROMETHAZINE/6.25MG/5ML

Facility

$15.00

Hospital Charge Code	60633759
Hospital Revenue Code	250
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$2.25
Rate for Payer: Qualcare PPO/HMO/WC	$2.25

PROMETHAZINE COD 6.25-10MG 5ML

Facility

$4.00

Service Code	NDC 603158558
Hospital Charge Code	60627994
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

PROMETHAZINE COD 6.25-10MG 5ML

Facility

$4.00

Service Code	NDC 603158558
Hospital Charge Code	60627994
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.52
Rate for Payer: Aetna Medicare Advantage	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.02
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.20
Rate for Payer: Oxford Commercial	$0.80
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$0.80
Rate for Payer: UnitedHealthcare Community & State	$0.10
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

PROMETHAZINE COD6.25MG/10MG/5M

Facility

$3.20

Hospital Charge Code	6021190
Hospital Revenue Code	251
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.48
Rate for Payer: Qualcare PPO/HMO/WC	$0.48

PROMETHAZINE COD6.25MG/10MG/5M

Facility

$3.20

Hospital Charge Code	6021190
Hospital Revenue Code	251
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna Commercial	$1.22
Rate for Payer: Aetna Medicare Advantage	$0.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.82
Rate for Payer: Cigna Commercial	$1.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.96
Rate for Payer: Oxford Commercial	$0.64
Rate for Payer: Qualcare PPO/HMO/WC	$0.48
Rate for Payer: UnitedHealthcare Commercial	$0.64
Rate for Payer: UnitedHealthcare Community & State	$0.08
Rate for Payer: Wellpoint Medicaid Managed Care	$0.08

Know your out-of-pocket cost for care.

All Charges