Heights University Hospital

All Charges

Charge

Type

Setting

Price

THEO-ORGANIDIN/480ML

Facility

$3.00

Hospital Charge Code	60634008
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Qualcare PPO/HMO/WC	$0.45

THEO-ORGANIDIN/480ML

Facility

$3.00

Hospital Charge Code	60634008
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna Commercial	$0.90
Rate for Payer: Aetna Medicare Advantage	$0.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.77
Rate for Payer: Cigna Commercial	$1.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.39
Rate for Payer: Oxford Commercial	$1.50
Rate for Payer: Qualcare PPO/HMO/WC	$0.45
Rate for Payer: UnitedHealthcare Commercial	$1.50

THEOPHYLLINE 100MG 24-HR CAPS

Facility

$13.27

Service Code	NDC 50474010001
Hospital Charge Code	606390077
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$6.63
Rate for Payer: Aetna Commercial	$3.98
Rate for Payer: Aetna Medicare Advantage	$3.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.38
Rate for Payer: Cigna Commercial	$6.63
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.73
Rate for Payer: Oxford Commercial	$6.63
Rate for Payer: Qualcare PPO/HMO/WC	$1.99
Rate for Payer: UnitedHealthcare Commercial	$6.63

THEOPHYLLINE 100MG 24-HR CAPS

Facility

$13.27

Service Code	NDC 50474010001
Hospital Charge Code	606390077
Hospital Revenue Code	250
Min. Negotiated Rate	$1.99
Max. Negotiated Rate	$1.99
Rate for Payer: Qualcare PPO/HMO/WC	$1.99

THEOPHYLLINE 125 MG ER CAP

Facility

$5.65

Hospital Charge Code	60629134
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$2.83
Rate for Payer: Aetna Commercial	$1.70
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	$0.73
Rate for Payer: Oxford Commercial	$2.83
Rate for Payer: Qualcare PPO/HMO/WC	$0.85
Rate for Payer: UnitedHealthcare Commercial	$2.83

THEOPHYLLINE 125 MG ER CAP

Facility

$5.65

Hospital Charge Code	60629134
Hospital Revenue Code	259
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.85
Rate for Payer: Qualcare PPO/HMO/WC	$0.85

THEOPHYLLINE 200 MG ER TAB

Facility

$4.69

Service Code	NDC 904588861
Hospital Charge Code	6022867
Hospital Revenue Code	251
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$2.35
Rate for Payer: Aetna Commercial	$1.41
Rate for Payer: Aetna Medicare Advantage	$1.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.20
Rate for Payer: Cigna Commercial	$2.35
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.61
Rate for Payer: Oxford Commercial	$2.35
Rate for Payer: Qualcare PPO/HMO/WC	$0.70
Rate for Payer: UnitedHealthcare Commercial	$2.35

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	$3.75
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna Commercial	$8.64
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	$3.75
Rate for Payer: Oxford Commercial	$14.40
Rate for Payer: Qualcare PPO/HMO/WC	$4.32
Rate for Payer: UnitedHealthcare Commercial	$14.40

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	$2.86
Max. Negotiated Rate	$11.00
Rate for Payer: Aetna Commercial	$6.60
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	$2.86
Rate for Payer: Oxford Commercial	$11.00
Rate for Payer: Qualcare PPO/HMO/WC	$3.30
Rate for Payer: UnitedHealthcare Commercial	$11.00

THEOPHYLLINE/80MG/15ML

Facility

$144.00

Hospital Charge Code	60634009
Hospital Revenue Code	250
Min. Negotiated Rate	$18.72
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$43.20
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	$18.72
Rate for Payer: Oxford Commercial	$72.00
Rate for Payer: Qualcare PPO/HMO/WC	$21.60
Rate for Payer: UnitedHealthcare Commercial	$72.00

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 80 MG/15 ML LIQ

Facility

$83.75

Service Code	NDC 70408064434
Hospital Charge Code	60628476
Hospital Revenue Code	250
Min. Negotiated Rate	$10.89
Max. Negotiated Rate	$41.88
Rate for Payer: Aetna Commercial	$25.12
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	$10.89
Rate for Payer: Oxford Commercial	$41.88
Rate for Payer: Qualcare PPO/HMO/WC	$12.56
Rate for Payer: UnitedHealthcare Commercial	$41.88

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	$7.07
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$45.81
Rate for Payer: Aetna Medicare Advantage	$14.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$51.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$51.81
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	$28.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$51.81
Rate for Payer: Cigna Commercial	$14.14
Rate for Payer: Cigna Medicare Advantage	$7.07
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: MagnaCare PPO/Direct Plus/Exchange/WC	$30.42
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$35.10
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.14
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$14.99
Rate for Payer: Wellcare Medicare Advantage	$14.14

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 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 ANH 200MG CAPS ER

Facility

$19.77

Service Code	NDC 50474020001
Hospital Charge Code	606390515
Hospital Revenue Code	250
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$9.88
Rate for Payer: Aetna Commercial	$5.93
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	$2.57
Rate for Payer: Oxford Commercial	$9.88
Rate for Payer: Qualcare PPO/HMO/WC	$2.97
Rate for Payer: UnitedHealthcare Commercial	$9.88

THEOPHYLLINE CAP CR 400MG

Facility

$7.25

Hospital Charge Code	60628859
Hospital Revenue Code	250
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$3.62
Rate for Payer: Aetna Commercial	$2.17
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	$0.94
Rate for Payer: Oxford Commercial	$3.62
Rate for Payer: Qualcare PPO/HMO/WC	$1.09
Rate for Payer: UnitedHealthcare Commercial	$3.62

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 SR 300MG

Facility

$3.20

Hospital Charge Code	60628475
Hospital Revenue Code	250
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

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 DF PINT

Facility

$19.85

Hospital Charge Code	6006282
Hospital Revenue Code	251
Min. Negotiated Rate	$2.58
Max. Negotiated Rate	$9.93
Rate for Payer: Aetna Commercial	$5.96
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	$2.58
Rate for Payer: Oxford Commercial	$9.93
Rate for Payer: Qualcare PPO/HMO/WC	$2.98
Rate for Payer: UnitedHealthcare Commercial	$9.93

Know your out-of-pocket cost for care.

All Charges