Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

PROMETHAZINE DM 15MG

Facility

$57.32

Hospital Charge Code	60635757
Hospital Revenue Code	250
Min. Negotiated Rate	$8.60
Max. Negotiated Rate	$8.60
Rate for Payer: Qualcare PPO/HMO/WC	$8.60

PROMETHAZINE DM 15MG

Facility

$57.32

Hospital Charge Code	60635757
Hospital Revenue Code	250
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$28.66
Rate for Payer: Aetna Commercial	$21.78
Rate for Payer: Aetna Medicare Advantage	$17.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.62
Rate for Payer: Cigna Commercial	$28.66
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$17.20
Rate for Payer: Oxford Commercial	$11.46
Rate for Payer: Qualcare PPO/HMO/WC	$8.60
Rate for Payer: UnitedHealthcare Commercial	$11.46
Rate for Payer: UnitedHealthcare Community & State	$1.38
Rate for Payer: Wellpoint Medicaid Managed Care	$1.52

PROMETHAZINE DM/4OZ

Facility

$7.00

Hospital Charge Code	60634622
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 DM/4OZ

Facility

$7.00

Hospital Charge Code	60634622
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.05
Rate for Payer: Qualcare PPO/HMO/WC	$1.05

PROMETHAZINE DM 6.25 15MG/5ML

Facility

$6.50

Service Code	NDC 60432060816
Hospital Charge Code	60628691
Hospital Revenue Code	250
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$0.98
Rate for Payer: Qualcare PPO/HMO/WC	$0.98

PROMETHAZINE DM 6.25 15MG/5ML

Facility

$6.50

Service Code	NDC 60432060816
Hospital Charge Code	60628691
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna Commercial	$2.47
Rate for Payer: Aetna Medicare Advantage	$1.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.66
Rate for Payer: Cigna Commercial	$3.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.95
Rate for Payer: Oxford Commercial	$1.30
Rate for Payer: Qualcare PPO/HMO/WC	$0.98
Rate for Payer: UnitedHealthcare Commercial	$1.30
Rate for Payer: UnitedHealthcare Community & State	$0.16
Rate for Payer: Wellpoint Medicaid Managed Care	$0.17

PROMETHAZINE-DM 6.25-15MG/5ML

Facility

$26.90

Hospital Charge Code	60627995
Hospital Revenue Code	250
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$4.04
Rate for Payer: Qualcare PPO/HMO/WC	$4.04

PROMETHAZINE-DM 6.25-15MG/5ML

Facility

$26.90

Hospital Charge Code	60627995
Hospital Revenue Code	250
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$13.45
Rate for Payer: Aetna Commercial	$10.22
Rate for Payer: Aetna Medicare Advantage	$8.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6.86
Rate for Payer: Cigna Commercial	$13.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8.07
Rate for Payer: Oxford Commercial	$5.38
Rate for Payer: Qualcare PPO/HMO/WC	$4.04
Rate for Payer: UnitedHealthcare Commercial	$5.38
Rate for Payer: UnitedHealthcare Community & State	$0.65
Rate for Payer: Wellpoint Medicaid Managed Care	$0.71

PROMETHAZINE DM 6.25MG/5L

Facility

$1.00

Hospital Charge Code	60635687
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: Qualcare PPO/HMO/WC	$0.15

PROMETHAZINE DM 6.25MG/5L

Facility

$1.00

Hospital Charge Code	60635687
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 DM SYRUP/GAL

Facility

$6.16

Service Code	NDC 64679060416
Hospital Charge Code	60634248
Hospital Revenue Code	250
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$0.92
Rate for Payer: Qualcare PPO/HMO/WC	$0.92

PROMETHAZINE DM SYRUP/GAL

Facility

$6.16

Service Code	NDC 64679060416
Hospital Charge Code	60634248
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$3.08
Rate for Payer: Aetna Commercial	$2.34
Rate for Payer: Aetna Medicare Advantage	$1.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.57
Rate for Payer: Cigna Commercial	$3.08
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.85
Rate for Payer: Oxford Commercial	$1.23
Rate for Payer: Qualcare PPO/HMO/WC	$0.92
Rate for Payer: UnitedHealthcare Commercial	$1.23
Rate for Payer: UnitedHealthcare Community & State	$0.15
Rate for Payer: Wellpoint Medicaid Managed Care	$0.16

PROMETHAZINE EXP W/DM LIQUID

Facility

$3.30

Hospital Charge Code	606350908
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Qualcare PPO/HMO/WC	$0.50

PROMETHAZINE EXP W/DM LIQUID

Facility

$3.30

Hospital Charge Code	606350908
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$1.65
Rate for Payer: Aetna Commercial	$1.25
Rate for Payer: Aetna Medicare Advantage	$0.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.84
Rate for Payer: Cigna Commercial	$1.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.99
Rate for Payer: Oxford Commercial	$0.66
Rate for Payer: Qualcare PPO/HMO/WC	$0.50
Rate for Payer: UnitedHealthcare Commercial	$0.66
Rate for Payer: UnitedHealthcare Community & State	$0.08
Rate for Payer: Wellpoint Medicaid Managed Care	$0.09

PROMETHAZINE PHENL 16OZ

Facility

$30.10

Hospital Charge Code	6004691
Hospital Revenue Code	251
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$15.05
Rate for Payer: Aetna Commercial	$11.44
Rate for Payer: Aetna Medicare Advantage	$9.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.68
Rate for Payer: Cigna Commercial	$15.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.03
Rate for Payer: Oxford Commercial	$6.02
Rate for Payer: Qualcare PPO/HMO/WC	$4.51
Rate for Payer: UnitedHealthcare Commercial	$6.02
Rate for Payer: UnitedHealthcare Community & State	$0.73
Rate for Payer: Wellpoint Medicaid Managed Care	$0.80

PROMETHAZINE PHENL 16OZ

Facility

$30.10

Hospital Charge Code	6004691
Hospital Revenue Code	251
Min. Negotiated Rate	$4.51
Max. Negotiated Rate	$4.51
Rate for Payer: Qualcare PPO/HMO/WC	$4.51

PROMETHAZINE PHENL COD LQ 16OZ

Facility

$41.60

Hospital Charge Code	6004683
Hospital Revenue Code	251
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$6.24
Rate for Payer: Qualcare PPO/HMO/WC	$6.24

PROMETHAZINE PHENL COD LQ 16OZ

Facility

$41.60

Hospital Charge Code	6004683
Hospital Revenue Code	251
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$20.80
Rate for Payer: Aetna Commercial	$15.81
Rate for Payer: Aetna Medicare Advantage	$12.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.61
Rate for Payer: Cigna Commercial	$20.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.48
Rate for Payer: Oxford Commercial	$8.32
Rate for Payer: Qualcare PPO/HMO/WC	$6.24
Rate for Payer: UnitedHealthcare Commercial	$8.32
Rate for Payer: UnitedHealthcare Community & State	$1.00
Rate for Payer: Wellpoint Medicaid Managed Care	$1.10

PROMETHAZINE SYR6.25MG/5ML120M

Facility

$32.65

Hospital Charge Code	60627233
Hospital Revenue Code	251
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$16.32
Rate for Payer: Aetna Commercial	$12.41
Rate for Payer: Aetna Medicare Advantage	$9.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8.33
Rate for Payer: Cigna Commercial	$16.32
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.79
Rate for Payer: Oxford Commercial	$6.53
Rate for Payer: Qualcare PPO/HMO/WC	$4.90
Rate for Payer: UnitedHealthcare Commercial	$6.53
Rate for Payer: UnitedHealthcare Community & State	$0.79
Rate for Payer: Wellpoint Medicaid Managed Care	$0.87

PROMETHAZINE SYR6.25MG/5ML120M

Facility

$32.65

Hospital Charge Code	60627233
Hospital Revenue Code	251
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$4.90
Rate for Payer: Qualcare PPO/HMO/WC	$4.90

PROMETHAZINE VC/120ML

Facility

$13.00

Hospital Charge Code	60633761
Hospital Revenue Code	250
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$1.95
Rate for Payer: Qualcare PPO/HMO/WC	$1.95

PROMETHAZINE VC/120ML

Facility

$13.00

Hospital Charge Code	60633761
Hospital Revenue Code	250
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$6.50
Rate for Payer: Aetna Commercial	$4.94
Rate for Payer: Aetna Medicare Advantage	$3.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.31
Rate for Payer: Cigna Commercial	$6.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.90
Rate for Payer: Oxford Commercial	$2.60
Rate for Payer: Qualcare PPO/HMO/WC	$1.95
Rate for Payer: UnitedHealthcare Commercial	$2.60
Rate for Payer: UnitedHealthcare Community & State	$0.31
Rate for Payer: Wellpoint Medicaid Managed Care	$0.34

PROMETHAZINE VC/480ML

Facility

$23.00

Hospital Charge Code	60633760
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$11.50
Rate for Payer: Aetna Commercial	$8.74
Rate for Payer: Aetna Medicare Advantage	$6.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.87
Rate for Payer: Cigna Commercial	$11.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.90
Rate for Payer: Oxford Commercial	$4.60
Rate for Payer: Qualcare PPO/HMO/WC	$3.45
Rate for Payer: UnitedHealthcare Commercial	$4.60
Rate for Payer: UnitedHealthcare Community & State	$0.55
Rate for Payer: Wellpoint Medicaid Managed Care	$0.61

PROMETHAZINE VC/480ML

Facility

$23.00

Hospital Charge Code	60633760
Hospital Revenue Code	250
Min. Negotiated Rate	$3.45
Max. Negotiated Rate	$3.45
Rate for Payer: Qualcare PPO/HMO/WC	$3.45

PROMETHAZINE VC W/ COD/16

Facility

$51.00

Hospital Charge Code	60634596
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$7.65
Rate for Payer: Qualcare PPO/HMO/WC	$7.65

Know your out-of-pocket cost for care.

All Charges