Hoboken 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	$0.11
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	$0.13
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

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	$0.19
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	$0.21
Rate for Payer: Wellpoint Medicaid Managed Care	$0.19

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 SUPP

Facility

$118.66

Service Code	NDC 45802075930
Hospital Charge Code	60627860
Hospital Revenue Code	250
Min. Negotiated Rate	$3.37
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	$30.85
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	$3.75
Rate for Payer: Wellpoint Medicaid Managed Care	$3.37

PROMETHAZINE 25 MG TAB

Facility

$4.00

Service Code	HCPCS Q0169
Hospital Charge Code	60629866
Hospital Revenue Code	636
Min. Negotiated Rate	$0.11
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	$0.13
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

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 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	$0.42
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	$0.47
Rate for Payer: Wellpoint Medicaid Managed Care	$0.42

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	$0.11
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	$1.04
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	$0.13
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

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	$0.18
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	$1.69
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	$0.21
Rate for Payer: Wellpoint Medicaid Managed Care	$0.18

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	$0.17
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	$1.60
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	$0.19
Rate for Payer: Wellpoint Medicaid Managed Care	$0.17

PROMETHEUS ANSER IFX

Facility

$340.81

Hospital Charge Code	397073689
Hospital Revenue Code	306
Min. Negotiated Rate	$9.68
Max. Negotiated Rate	$170.41
Rate for Payer: Aetna Commercial	$129.51
Rate for Payer: Aetna Medicare Advantage	$102.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$86.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$86.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$86.91
Rate for Payer: Cigna Commercial	$170.41
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$88.61
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$51.12
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$10.77
Rate for Payer: Wellpoint Medicaid Managed Care	$9.68

PROMETHEUS ANSER IFX

Facility

$667.59

Service Code	HCPCS 83520
Hospital Charge Code	397080006
Hospital Revenue Code	306
Min. Negotiated Rate	$100.14
Max. Negotiated Rate	$100.14
Rate for Payer: Qualcare PPO/HMO/WC	$100.14

PROMETHEUS ANSER IFX

Facility

$667.59

Service Code	HCPCS 83520
Hospital Charge Code	397080006
Hospital Revenue Code	306
Min. Negotiated Rate	$12.11
Max. Negotiated Rate	$333.80
Rate for Payer: Aetna Commercial	$46.97
Rate for Payer: Aetna Medicare Advantage	$55.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$62.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$62.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$17.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$12.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$62.65
Rate for Payer: Cigna Commercial	$333.80
Rate for Payer: Cigna Medicare Advantage	$17.27
Rate for Payer: Clover Medicare Advantage	$16.41
Rate for Payer: EmblemHealth Commercial	$51.81
Rate for Payer: Humana Medicare Advantage	$17.79
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$17.27
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$173.57
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$100.14
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$13.82
Rate for Payer: UnitedHealthcare Medicare Advantage	$17.27
Rate for Payer: Wellcare Medicare Advantage	$17.27
Rate for Payer: Wellpoint Medicaid Managed Care	$18.96

PROMETHEUS ANSER IFX

Facility

$340.81

Hospital Charge Code	397073689
Hospital Revenue Code	306
Min. Negotiated Rate	$51.12
Max. Negotiated Rate	$51.12
Rate for Payer: Qualcare PPO/HMO/WC	$51.12

PROPAFENONE 150 MG TAB

Facility

$21.17

Service Code	NDC 173079220
Hospital Charge Code	60628853
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$10.59
Rate for Payer: Aetna Commercial	$8.04
Rate for Payer: Aetna Medicare Advantage	$6.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.40
Rate for Payer: Cigna Commercial	$10.59
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.50
Rate for Payer: Oxford Commercial	$4.23
Rate for Payer: Qualcare PPO/HMO/WC	$3.18
Rate for Payer: UnitedHealthcare Commercial	$4.23
Rate for Payer: UnitedHealthcare Community & State	$0.67
Rate for Payer: Wellpoint Medicaid Managed Care	$0.60

PROPAFENONE 150 MG TAB

Facility

$21.17

Service Code	NDC 173079220
Hospital Charge Code	60628853
Hospital Revenue Code	250
Min. Negotiated Rate	$3.18
Max. Negotiated Rate	$3.18
Rate for Payer: Qualcare PPO/HMO/WC	$3.18

PROPAFENONE HCL 225 MG TAB

Facility

$15.61

Service Code	NDC 591058301
Hospital Charge Code	606390056
Hospital Revenue Code	250
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$7.80
Rate for Payer: Aetna Commercial	$5.93
Rate for Payer: Aetna Medicare Advantage	$4.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.98
Rate for Payer: Cigna Commercial	$7.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.06
Rate for Payer: Oxford Commercial	$3.12
Rate for Payer: Qualcare PPO/HMO/WC	$2.34
Rate for Payer: UnitedHealthcare Commercial	$3.12
Rate for Payer: UnitedHealthcare Community & State	$0.49
Rate for Payer: Wellpoint Medicaid Managed Care	$0.44

PROPAFENONE HCL 225 MG TAB

Facility

$15.61

Service Code	NDC 591058301
Hospital Charge Code	606390056
Hospital Revenue Code	250
Min. Negotiated Rate	$2.34
Max. Negotiated Rate	$2.34
Rate for Payer: Qualcare PPO/HMO/WC	$2.34

Know your out-of-pocket cost for care.

All Charges