Heights University Hospital

All Charges

Charge

Type

Setting

Price

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	$0.65
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna Commercial	$1.50
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	$0.65
Rate for Payer: Oxford Commercial	$2.50
Rate for Payer: Qualcare PPO/HMO/WC	$0.75
Rate for Payer: UnitedHealthcare Commercial	$2.50

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	$0.65
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna Commercial	$1.50
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	$0.65
Rate for Payer: Oxford Commercial	$2.50
Rate for Payer: Qualcare PPO/HMO/WC	$0.75
Rate for Payer: UnitedHealthcare Commercial	$2.50

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 ER 200mg

Facility

$19.77

Service Code	NDC 50474020001
Hospital Charge Code	606390079
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 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 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 300mg

Facility

$24.25

Service Code	NDC 50474030001
Hospital Charge Code	606390080
Hospital Revenue Code	250
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$12.12
Rate for Payer: Aetna Commercial	$7.28
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	$3.15
Rate for Payer: Oxford Commercial	$12.12
Rate for Payer: Qualcare PPO/HMO/WC	$3.64
Rate for Payer: UnitedHealthcare Commercial	$12.12

THEOPHYLLINE ER 400MG TAB

Facility

$9.11

Service Code	NDC 378048601
Hospital Charge Code	606361043
Hospital Revenue Code	250
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$4.55
Rate for Payer: Aetna Commercial	$2.73
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	$1.18
Rate for Payer: Oxford Commercial	$4.55
Rate for Payer: Qualcare PPO/HMO/WC	$1.37
Rate for Payer: UnitedHealthcare Commercial	$4.55

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	$0.85
Max. Negotiated Rate	$0.85
Rate for Payer: Qualcare PPO/HMO/WC	$0.85

THEOPHYLLINE GUAIF CAP150 90MG

Facility

$5.65

Hospital Charge Code	60628479
Hospital Revenue Code	250
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 GUAIF SYRP

Facility

$4.50

Hospital Charge Code	60628480
Hospital Revenue Code	250
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$2.25
Rate for Payer: Aetna Commercial	$1.35
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	$0.59
Rate for Payer: Oxford Commercial	$2.25
Rate for Payer: Qualcare PPO/HMO/WC	$0.68
Rate for Payer: UnitedHealthcare Commercial	$2.25

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 INJ 800MG IN D5W

Facility

$131.85

Hospital Charge Code	6005284
Hospital Revenue Code	250
Min. Negotiated Rate	$17.14
Max. Negotiated Rate	$65.92
Rate for Payer: Aetna Commercial	$39.55
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	$17.14
Rate for Payer: Oxford Commercial	$65.92
Rate for Payer: Qualcare PPO/HMO/WC	$19.78
Rate for Payer: UnitedHealthcare Commercial	$65.92

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 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 IV800MG/500ML D5W

Facility

$160.85

Hospital Charge Code	60628478
Hospital Revenue Code	250
Min. Negotiated Rate	$20.91
Max. Negotiated Rate	$80.42
Rate for Payer: Aetna Commercial	$48.26
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	$20.91
Rate for Payer: Oxford Commercial	$80.42
Rate for Payer: Qualcare PPO/HMO/WC	$24.13
Rate for Payer: UnitedHealthcare Commercial	$80.42

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	$0.73
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, SERUM

Facility

$390.00

Service Code	HCPCS 80198
Hospital Charge Code	3003969
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	$50.70
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
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, 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 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	$14.23
Max. Negotiated Rate	$54.73
Rate for Payer: Aetna Commercial	$32.84
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	$14.23
Rate for Payer: Oxford Commercial	$54.73
Rate for Payer: Qualcare PPO/HMO/WC	$16.42
Rate for Payer: UnitedHealthcare Commercial	$54.73

Know your out-of-pocket cost for care.

All Charges