Heights University Hospital

All Charges

Charge

Type

Setting

Price

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	$1.02
Max. Negotiated Rate	$3.34
Rate for Payer: Aetna Commercial	$2.03
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	$3.34
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.64
Rate for Payer: Qualcare PPO/HMO/WC	$1.02

PROMETHAZINE 25 MG SUPP

Facility

$118.66

Service Code	NDC 45802075930
Hospital Charge Code	60627860
Hospital Revenue Code	250
Min. Negotiated Rate	$15.43
Max. Negotiated Rate	$59.33
Rate for Payer: Aetna Commercial	$35.60
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	$15.43
Rate for Payer: Oxford Commercial	$59.33
Rate for Payer: Qualcare PPO/HMO/WC	$17.80
Rate for Payer: UnitedHealthcare Commercial	$59.33

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	$2.00
Rate for Payer: Aetna Commercial	$1.20
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

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/50MG/1ML

Facility

$7.00

Hospital Charge Code	60633758
Hospital Revenue Code	250
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$3.50
Rate for Payer: Aetna Commercial	$2.10
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	$0.91
Rate for Payer: Oxford Commercial	$3.50
Rate for Payer: Qualcare PPO/HMO/WC	$1.05
Rate for Payer: UnitedHealthcare Commercial	$3.50

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 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	$2.23
Max. Negotiated Rate	$4.46
Rate for Payer: Aetna Commercial	$4.46
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	$3.34
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.60
Rate for Payer: Qualcare PPO/HMO/WC	$2.23

PROMETHAZINE 6.25MG

Facility

$88.80

Hospital Charge Code	60635758
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$44.40
Rate for Payer: Aetna Commercial	$26.64
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	$11.54
Rate for Payer: Oxford Commercial	$44.40
Rate for Payer: Qualcare PPO/HMO/WC	$13.32
Rate for Payer: UnitedHealthcare Commercial	$44.40

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/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

$1.00

Hospital Charge Code	60635689
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna Commercial	$0.30
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	$0.13
Rate for Payer: Oxford Commercial	$0.50
Rate for Payer: Qualcare PPO/HMO/WC	$0.15
Rate for Payer: UnitedHealthcare Commercial	$0.50

PROMETHAZINE/6.25MG/5ML

Facility

$15.00

Hospital Charge Code	60633759
Hospital Revenue Code	250
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna Commercial	$4.50
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	$1.95
Rate for Payer: Oxford Commercial	$7.50
Rate for Payer: Qualcare PPO/HMO/WC	$2.25
Rate for Payer: UnitedHealthcare Commercial	$7.50

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	$0.52
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.20
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	$0.52
Rate for Payer: Oxford Commercial	$2.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$2.00

PROMETHAZINE COD6.25MG/10MG/5M

Facility

$3.20

Hospital Charge Code	6021190
Hospital Revenue Code	251
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna Commercial	$0.96
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	$0.42
Rate for Payer: Oxford Commercial	$1.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.48
Rate for Payer: UnitedHealthcare Commercial	$1.60

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 DM 15MG

Facility

$57.32

Hospital Charge Code	60635757
Hospital Revenue Code	250
Min. Negotiated Rate	$7.45
Max. Negotiated Rate	$28.66
Rate for Payer: Aetna Commercial	$17.20
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	$7.45
Rate for Payer: Oxford Commercial	$28.66
Rate for Payer: Qualcare PPO/HMO/WC	$8.60
Rate for Payer: UnitedHealthcare Commercial	$28.66

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/4OZ

Facility

$7.00

Hospital Charge Code	60634622
Hospital Revenue Code	250
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$3.50
Rate for Payer: Aetna Commercial	$2.10
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	$0.91
Rate for Payer: Oxford Commercial	$3.50
Rate for Payer: Qualcare PPO/HMO/WC	$1.05
Rate for Payer: UnitedHealthcare Commercial	$3.50

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

Know your out-of-pocket cost for care.

All Charges