Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

THEOPHYLLINE 200 MG ER TAB

Facility

$4.69

Service Code	NDC 904588861
Hospital Charge Code	6022867
Hospital Revenue Code	251
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$0.70
Rate for Payer: Qualcare PPO/HMO/WC	$0.70

THEOPHYLLINE 300 MG ER CAP

Facility

$28.81

Service Code	NDC 62332002531
Hospital Charge Code	60628473
Hospital Revenue Code	250
Min. Negotiated Rate	$4.32
Max. Negotiated Rate	$4.32
Rate for Payer: Qualcare PPO/HMO/WC	$4.32

THEOPHYLLINE 300 MG ER CAP

Facility

$28.81

Service Code	NDC 62332002531
Hospital Charge Code	60628473
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna Commercial	$10.95
Rate for Payer: Aetna Medicare Advantage	$8.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.35
Rate for Payer: Cigna Commercial	$14.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8.64
Rate for Payer: Oxford Commercial	$5.76
Rate for Payer: Qualcare PPO/HMO/WC	$4.32
Rate for Payer: UnitedHealthcare Commercial	$5.76
Rate for Payer: UnitedHealthcare Community & State	$0.69
Rate for Payer: Wellpoint Medicaid Managed Care	$0.76

THEOPHYLLINE 400MG PM

Facility

$22.00

Hospital Charge Code	60635558
Hospital Revenue Code	250
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$3.30
Rate for Payer: Qualcare PPO/HMO/WC	$3.30

THEOPHYLLINE 400MG PM

Facility

$22.00

Hospital Charge Code	60635558
Hospital Revenue Code	250
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$11.00
Rate for Payer: Aetna Commercial	$8.36
Rate for Payer: Aetna Medicare Advantage	$6.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.61
Rate for Payer: Cigna Commercial	$11.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.60
Rate for Payer: Oxford Commercial	$4.40
Rate for Payer: Qualcare PPO/HMO/WC	$3.30
Rate for Payer: UnitedHealthcare Commercial	$4.40
Rate for Payer: UnitedHealthcare Community & State	$0.53
Rate for Payer: Wellpoint Medicaid Managed Care	$0.58

THEOPHYLLINE/80MG/15ML

Facility

$144.00

Hospital Charge Code	60634009
Hospital Revenue Code	250
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$21.60
Rate for Payer: Qualcare PPO/HMO/WC	$21.60

THEOPHYLLINE/80MG/15ML

Facility

$144.00

Hospital Charge Code	60634009
Hospital Revenue Code	250
Min. Negotiated Rate	$3.47
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$54.72
Rate for Payer: Aetna Medicare Advantage	$43.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$36.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$36.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$36.72
Rate for Payer: Cigna Commercial	$72.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$43.20
Rate for Payer: Oxford Commercial	$28.80
Rate for Payer: Qualcare PPO/HMO/WC	$21.60
Rate for Payer: UnitedHealthcare Commercial	$28.80
Rate for Payer: UnitedHealthcare Community & State	$3.47
Rate for Payer: Wellpoint Medicaid Managed Care	$3.82

THEOPHYLLINE 80 MG/15 ML LIQ

Facility

$83.75

Service Code	NDC 70408064434
Hospital Charge Code	60628476
Hospital Revenue Code	250
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$41.88
Rate for Payer: Aetna Commercial	$31.82
Rate for Payer: Aetna Medicare Advantage	$25.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$21.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$21.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$21.36
Rate for Payer: Cigna Commercial	$41.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$25.12
Rate for Payer: Oxford Commercial	$16.75
Rate for Payer: Qualcare PPO/HMO/WC	$12.56
Rate for Payer: UnitedHealthcare Commercial	$16.75
Rate for Payer: UnitedHealthcare Community & State	$2.02
Rate for Payer: Wellpoint Medicaid Managed Care	$2.22

THEOPHYLLINE 80 MG/15 ML LIQ

Facility

$83.75

Service Code	NDC 70408064434
Hospital Charge Code	60628476
Hospital Revenue Code	250
Min. Negotiated Rate	$12.56
Max. Negotiated Rate	$12.56
Rate for Payer: Qualcare PPO/HMO/WC	$12.56

THEOPHYLLINE (AMINOPHYLLINE)

Facility

$234.00

Service Code	HCPCS 80198
Hospital Charge Code	38472641
Hospital Revenue Code	301
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$35.10
Rate for Payer: Qualcare PPO/HMO/WC	$35.10

THEOPHYLLINE (AMINOPHYLLINE)

Facility

$234.00

Service Code	HCPCS 80198
Hospital Charge Code	38472641
Hospital Revenue Code	301
Min. Negotiated Rate	$6.20
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$38.46
Rate for Payer: Aetna Medicare Advantage	$45.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$51.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$51.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$29.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$51.04
Rate for Payer: Cigna Commercial	$117.00
Rate for Payer: Cigna Medicare Advantage	$14.14
Rate for Payer: Clover Medicare Advantage	$13.43
Rate for Payer: EmblemHealth Commercial	$42.42
Rate for Payer: Humana Medicare Advantage	$14.56
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$70.20
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$35.10
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$11.31
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.14
Rate for Payer: Wellcare Medicare Advantage	$14.14
Rate for Payer: Wellpoint Medicaid Managed Care	$6.20

THEOPHYLLINE ANH 200MG CAPS ER

Facility

$19.77

Service Code	NDC 50474020001
Hospital Charge Code	606390515
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$9.88
Rate for Payer: Aetna Commercial	$7.51
Rate for Payer: Aetna Medicare Advantage	$5.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.04
Rate for Payer: Cigna Commercial	$9.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.93
Rate for Payer: Oxford Commercial	$3.95
Rate for Payer: Qualcare PPO/HMO/WC	$2.97
Rate for Payer: UnitedHealthcare Commercial	$3.95
Rate for Payer: UnitedHealthcare Community & State	$0.48
Rate for Payer: Wellpoint Medicaid Managed Care	$0.52

THEOPHYLLINE ANH 200MG CAPS ER

Facility

$19.77

Service Code	NDC 50474020001
Hospital Charge Code	606390515
Hospital Revenue Code	250
Min. Negotiated Rate	$2.97
Max. Negotiated Rate	$2.97
Rate for Payer: Qualcare PPO/HMO/WC	$2.97

THEOPHYLLINE CAP CR 400MG

Facility

$7.25

Hospital Charge Code	60628859
Hospital Revenue Code	250
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.09
Rate for Payer: Qualcare PPO/HMO/WC	$1.09

THEOPHYLLINE CAP CR 400MG

Facility

$7.25

Hospital Charge Code	60628859
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$3.62
Rate for Payer: Aetna Commercial	$2.75
Rate for Payer: Aetna Medicare Advantage	$2.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.85
Rate for Payer: Cigna Commercial	$3.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.17
Rate for Payer: Oxford Commercial	$1.45
Rate for Payer: Qualcare PPO/HMO/WC	$1.09
Rate for Payer: UnitedHealthcare Commercial	$1.45
Rate for Payer: UnitedHealthcare Community & State	$0.17
Rate for Payer: Wellpoint Medicaid Managed Care	$0.19

THEOPHYLLINE CAP SR 300MG

Facility

$3.20

Hospital Charge Code	60628475
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.48
Rate for Payer: Qualcare PPO/HMO/WC	$0.48

THEOPHYLLINE CAP SR 300MG

Facility

$3.20

Hospital Charge Code	60628475
Hospital Revenue Code	250
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

THEOPHYLLINE DF PINT

Facility

$19.85

Hospital Charge Code	6006282
Hospital Revenue Code	251
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$9.93
Rate for Payer: Aetna Commercial	$7.54
Rate for Payer: Aetna Medicare Advantage	$5.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.06
Rate for Payer: Cigna Commercial	$9.93
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.96
Rate for Payer: Oxford Commercial	$3.97
Rate for Payer: Qualcare PPO/HMO/WC	$2.98
Rate for Payer: UnitedHealthcare Commercial	$3.97
Rate for Payer: UnitedHealthcare Community & State	$0.48
Rate for Payer: Wellpoint Medicaid Managed Care	$0.53

THEOPHYLLINE DF PINT

Facility

$19.85

Hospital Charge Code	6006282
Hospital Revenue Code	251
Min. Negotiated Rate	$2.98
Max. Negotiated Rate	$2.98
Rate for Payer: Qualcare PPO/HMO/WC	$2.98

THEOPHYLLINE ELIXIR/15ML

Facility

$5.00

Hospital Charge Code	60634608
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna Commercial	$1.90
Rate for Payer: Aetna Medicare Advantage	$1.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.27
Rate for Payer: Cigna Commercial	$2.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.50
Rate for Payer: Oxford Commercial	$1.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.75
Rate for Payer: UnitedHealthcare Commercial	$1.00
Rate for Payer: UnitedHealthcare Community & State	$0.12
Rate for Payer: Wellpoint Medicaid Managed Care	$0.13

THEOPHYLLINE ELIXIR/15ML

Facility

$5.00

Hospital Charge Code	60634608
Hospital Revenue Code	250
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$0.75
Rate for Payer: Qualcare PPO/HMO/WC	$0.75

THEOPHYLLINE ELIXIR/30ML

Facility

$5.00

Hospital Charge Code	60634607
Hospital Revenue Code	250
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$0.75
Rate for Payer: Qualcare PPO/HMO/WC	$0.75

THEOPHYLLINE ELIXIR/30ML

Facility

$5.00

Hospital Charge Code	60634607
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna Commercial	$1.90
Rate for Payer: Aetna Medicare Advantage	$1.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.27
Rate for Payer: Cigna Commercial	$2.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.50
Rate for Payer: Oxford Commercial	$1.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.75
Rate for Payer: UnitedHealthcare Commercial	$1.00
Rate for Payer: UnitedHealthcare Community & State	$0.12
Rate for Payer: Wellpoint Medicaid Managed Care	$0.13

Theophylline ER 200mg

Facility

$19.77

Service Code	NDC 50474020001
Hospital Charge Code	606390079
Hospital Revenue Code	250
Min. Negotiated Rate	$2.97
Max. Negotiated Rate	$2.97
Rate for Payer: Qualcare PPO/HMO/WC	$2.97

Theophylline ER 200mg

Facility

$19.77

Service Code	NDC 50474020001
Hospital Charge Code	606390079
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$9.88
Rate for Payer: Aetna Commercial	$7.51
Rate for Payer: Aetna Medicare Advantage	$5.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.04
Rate for Payer: Cigna Commercial	$9.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.93
Rate for Payer: Oxford Commercial	$3.95
Rate for Payer: Qualcare PPO/HMO/WC	$2.97
Rate for Payer: UnitedHealthcare Commercial	$3.95
Rate for Payer: UnitedHealthcare Community & State	$0.48
Rate for Payer: Wellpoint Medicaid Managed Care	$0.52

Know your out-of-pocket cost for care.

All Charges