Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

Theophylline ER 300mg

Facility

$24.25

Service Code	NDC 50474030001
Hospital Charge Code	606390080
Hospital Revenue Code	250
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$12.12
Rate for Payer: Aetna Commercial	$9.21
Rate for Payer: Aetna Medicare Advantage	$7.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6.18
Rate for Payer: Cigna Commercial	$12.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.28
Rate for Payer: Oxford Commercial	$4.85
Rate for Payer: Qualcare PPO/HMO/WC	$3.64
Rate for Payer: UnitedHealthcare Commercial	$4.85
Rate for Payer: UnitedHealthcare Community & State	$0.58
Rate for Payer: Wellpoint Medicaid Managed Care	$0.64

Theophylline ER 300mg

Facility

$24.25

Service Code	NDC 50474030001
Hospital Charge Code	606390080
Hospital Revenue Code	250
Min. Negotiated Rate	$3.64
Max. Negotiated Rate	$3.64
Rate for Payer: Qualcare PPO/HMO/WC	$3.64

THEOPHYLLINE ER 400MG TAB

Facility

$9.11

Service Code	NDC 378048601
Hospital Charge Code	606361043
Hospital Revenue Code	250
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$4.55
Rate for Payer: Aetna Commercial	$3.46
Rate for Payer: Aetna Medicare Advantage	$2.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.32
Rate for Payer: Cigna Commercial	$4.55
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.73
Rate for Payer: Oxford Commercial	$1.82
Rate for Payer: Qualcare PPO/HMO/WC	$1.37
Rate for Payer: UnitedHealthcare Commercial	$1.82
Rate for Payer: UnitedHealthcare Community & State	$0.22
Rate for Payer: Wellpoint Medicaid Managed Care	$0.24

THEOPHYLLINE ER 400MG TAB

Facility

$9.11

Service Code	NDC 378048601
Hospital Charge Code	606361043
Hospital Revenue Code	250
Min. Negotiated Rate	$1.37
Max. Negotiated Rate	$1.37
Rate for Payer: Qualcare PPO/HMO/WC	$1.37

THEOPHYLLINE GUAIF CAP150 90MG

Facility

$5.65

Hospital Charge Code	60628479
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$2.83
Rate for Payer: Aetna Commercial	$2.15
Rate for Payer: Aetna Medicare Advantage	$1.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.44
Rate for Payer: Cigna Commercial	$2.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.70
Rate for Payer: Oxford Commercial	$1.13
Rate for Payer: Qualcare PPO/HMO/WC	$0.85
Rate for Payer: UnitedHealthcare Commercial	$1.13
Rate for Payer: UnitedHealthcare Community & State	$0.14
Rate for Payer: Wellpoint Medicaid Managed Care	$0.15

THEOPHYLLINE GUAIF CAP150 90MG

Facility

$5.65

Hospital Charge Code	60628479
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.85
Rate for Payer: Qualcare PPO/HMO/WC	$0.85

THEOPHYLLINE GUAIF SYRP

Facility

$4.50

Hospital Charge Code	60628480
Hospital Revenue Code	250
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.68
Rate for Payer: Qualcare PPO/HMO/WC	$0.68

THEOPHYLLINE GUAIF SYRP

Facility

$4.50

Hospital Charge Code	60628480
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$2.25
Rate for Payer: Aetna Commercial	$1.71
Rate for Payer: Aetna Medicare Advantage	$1.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.15
Rate for Payer: Cigna Commercial	$2.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.35
Rate for Payer: Oxford Commercial	$0.90
Rate for Payer: Qualcare PPO/HMO/WC	$0.68
Rate for Payer: UnitedHealthcare Commercial	$0.90
Rate for Payer: UnitedHealthcare Community & State	$0.11
Rate for Payer: Wellpoint Medicaid Managed Care	$0.12

THEOPHYLLINE INJ 800MG IN D5W

Facility

$131.85

Hospital Charge Code	6005284
Hospital Revenue Code	250
Min. Negotiated Rate	$19.78
Max. Negotiated Rate	$19.78
Rate for Payer: Qualcare PPO/HMO/WC	$19.78

THEOPHYLLINE INJ 800MG IN D5W

Facility

$131.85

Hospital Charge Code	6005284
Hospital Revenue Code	250
Min. Negotiated Rate	$3.18
Max. Negotiated Rate	$65.92
Rate for Payer: Aetna Commercial	$50.10
Rate for Payer: Aetna Medicare Advantage	$39.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$33.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$33.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$33.62
Rate for Payer: Cigna Commercial	$65.92
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$39.55
Rate for Payer: Oxford Commercial	$26.37
Rate for Payer: Qualcare PPO/HMO/WC	$19.78
Rate for Payer: UnitedHealthcare Commercial	$26.37
Rate for Payer: UnitedHealthcare Community & State	$3.18
Rate for Payer: Wellpoint Medicaid Managed Care	$3.49

THEOPHYLLINE IV800MG/500ML D5W

Facility

$160.85

Hospital Charge Code	60628478
Hospital Revenue Code	250
Min. Negotiated Rate	$3.88
Max. Negotiated Rate	$80.42
Rate for Payer: Aetna Commercial	$61.12
Rate for Payer: Aetna Medicare Advantage	$48.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$41.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$41.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$41.02
Rate for Payer: Cigna Commercial	$80.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$48.26
Rate for Payer: Oxford Commercial	$32.17
Rate for Payer: Qualcare PPO/HMO/WC	$24.13
Rate for Payer: UnitedHealthcare Commercial	$32.17
Rate for Payer: UnitedHealthcare Community & State	$3.88
Rate for Payer: Wellpoint Medicaid Managed Care	$4.26

THEOPHYLLINE IV800MG/500ML D5W

Facility

$160.85

Hospital Charge Code	60628478
Hospital Revenue Code	250
Min. Negotiated Rate	$24.13
Max. Negotiated Rate	$24.13
Rate for Payer: Qualcare PPO/HMO/WC	$24.13

THEOPHYLLINE LQ UD 80MG/15ML

Facility

$5.65

Hospital Charge Code	60628477
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.85
Rate for Payer: Qualcare PPO/HMO/WC	$0.85

THEOPHYLLINE LQ UD 80MG/15ML

Facility

$5.65

Hospital Charge Code	60628477
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$2.83
Rate for Payer: Aetna Commercial	$2.15
Rate for Payer: Aetna Medicare Advantage	$1.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.44
Rate for Payer: Cigna Commercial	$2.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.70
Rate for Payer: Oxford Commercial	$1.13
Rate for Payer: Qualcare PPO/HMO/WC	$0.85
Rate for Payer: UnitedHealthcare Commercial	$1.13
Rate for Payer: UnitedHealthcare Community & State	$0.14
Rate for Payer: Wellpoint Medicaid Managed Care	$0.15

THEOPHYLLINE, SERUM

Facility

$390.00

Service Code	HCPCS 80198
Hospital Charge Code	3003969
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

THEOPHYLLINE, SERUM

Facility

$390.00

Service Code	HCPCS 80198
Hospital Charge Code	3003969
Hospital Revenue Code	301
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
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	$195.00
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	$117.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
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	$10.34

THEOPHYLLINE SOL 80MG/15ML

Facility

$109.45

Hospital Charge Code	6005276
Hospital Revenue Code	251
Min. Negotiated Rate	$16.42
Max. Negotiated Rate	$16.42
Rate for Payer: Qualcare PPO/HMO/WC	$16.42

THEOPHYLLINE SOL 80MG/15ML

Facility

$109.45

Hospital Charge Code	6005276
Hospital Revenue Code	251
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$54.73
Rate for Payer: Aetna Commercial	$41.59
Rate for Payer: Aetna Medicare Advantage	$32.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$27.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$27.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$27.91
Rate for Payer: Cigna Commercial	$54.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$32.84
Rate for Payer: Oxford Commercial	$21.89
Rate for Payer: Qualcare PPO/HMO/WC	$16.42
Rate for Payer: UnitedHealthcare Commercial	$21.89
Rate for Payer: UnitedHealthcare Community & State	$2.64
Rate for Payer: Wellpoint Medicaid Managed Care	$2.90

THEOPHYLLINE TAB 100MG IR

Facility

$3.20

Hospital Charge Code	60628472
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 TAB 100MG IR

Facility

$3.20

Hospital Charge Code	60628472
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.48
Rate for Payer: Qualcare PPO/HMO/WC	$0.48

THEOPHYLLINE TAB SR 100MG*****

Facility

$6.00

Service Code	HCPCS J8499
Hospital Charge Code	60628474
Hospital Revenue Code	250
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$0.90
Rate for Payer: Qualcare PPO/HMO/WC	$0.90

THEOPHYLLINE TAB SR 100MG*****

Facility

$6.00

Service Code	HCPCS J8499
Hospital Charge Code	60628474
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna Commercial	$2.28
Rate for Payer: Aetna Medicare Advantage	$1.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.53
Rate for Payer: Cigna Commercial	$3.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.80
Rate for Payer: Oxford Commercial	$1.20
Rate for Payer: Qualcare PPO/HMO/WC	$0.90
Rate for Payer: UnitedHealthcare Commercial	$1.20
Rate for Payer: UnitedHealthcare Community & State	$0.14
Rate for Payer: Wellpoint Medicaid Managed Care	$0.16

THEOPHYLLINE TAB SR 400MG

Facility

$7.70

Hospital Charge Code	60628719
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$3.85
Rate for Payer: Aetna Commercial	$2.93
Rate for Payer: Aetna Medicare Advantage	$2.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.96
Rate for Payer: Cigna Commercial	$3.85
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.31
Rate for Payer: Oxford Commercial	$1.54
Rate for Payer: Qualcare PPO/HMO/WC	$1.16
Rate for Payer: UnitedHealthcare Commercial	$1.54
Rate for Payer: UnitedHealthcare Community & State	$0.19
Rate for Payer: Wellpoint Medicaid Managed Care	$0.20

THEOPHYLLINE TAB SR 400MG

Facility

$7.70

Hospital Charge Code	60628719
Hospital Revenue Code	250
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.16
Rate for Payer: Qualcare PPO/HMO/WC	$1.16

THEOPHYLLINE TAB SR 600MG

Facility

$8.35

Hospital Charge Code	60628720
Hospital Revenue Code	250
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.25
Rate for Payer: Qualcare PPO/HMO/WC	$1.25

Know your out-of-pocket cost for care.

All Charges