|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [204866]
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
NDC 00065074114
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.09 |
| Max. Negotiated Rate |
$57.23 |
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$56.05
|
| Rate for Payer: Health Management Network Commercial |
$50.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.09
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
| Rate for Payer: University Health Alliance Commercial |
$43.01
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [204866]
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
NDC 00065074114
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.15 |
| Max. Negotiated Rate |
$57.23 |
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Health Management Network Commercial |
$50.15
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
|
|
TETRAHYDROZOLINE 0.05 % EYE DROPS [7800]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00536121794
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
TETRAHYDROZOLINE 0.05 % EYE DROPS [7800]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00536121794
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
TFNA 9/130 340/RT 04.037.954S
|
Facility
|
OP
|
$5,973.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,046.23 |
| Max. Negotiated Rate |
$5,793.81 |
| Rate for Payer: Cash Price |
$3,583.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,181.10
|
| Rate for Payer: Health Management Network Commercial |
$5,077.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,762.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,046.23
|
| Rate for Payer: MDX Hawaii PPO |
$5,793.81
|
| Rate for Payer: University Health Alliance Commercial |
$3,344.88
|
|
|
TFNA 9/130 340/RT 04.037.954S
|
Facility
|
IP
|
$5,973.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,344.88 |
| Max. Negotiated Rate |
$5,793.81 |
| Rate for Payer: Cash Price |
$3,583.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,181.10
|
| Rate for Payer: Health Management Network Commercial |
$5,077.05
|
| Rate for Payer: MDX Hawaii PPO |
$5,793.81
|
| Rate for Payer: University Health Alliance Commercial |
$3,344.88
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
|
OP
|
$166.00
|
|
|
Service Code
|
NDC 27808003301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.66 |
| Max. Negotiated Rate |
$161.02 |
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$157.70
|
| Rate for Payer: Health Management Network Commercial |
$141.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$84.66
|
| Rate for Payer: MDX Hawaii PPO |
$161.02
|
| Rate for Payer: University Health Alliance Commercial |
$121.00
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
|
IP
|
$166.00
|
|
|
Service Code
|
NDC 27808003301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$141.10 |
| Max. Negotiated Rate |
$161.02 |
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Health Management Network Commercial |
$141.10
|
| Rate for Payer: MDX Hawaii PPO |
$161.02
|
|
|
THEOPHYLLINE ER 100 MG CAPSULE,EXTENDED RELEASE 24 HR [27418]
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
NDC 52244010010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.67 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.67
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
|
|
THEOPHYLLINE ER 100 MG CAPSULE,EXTENDED RELEASE 24 HR [27418]
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
NDC 52244010010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.45 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 68462072101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 68462072101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J3411
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.79
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39.90
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.42
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.20
|
| Rate for Payer: University Health Alliance Commercial |
$30.61
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J3411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [11538]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 93425000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [11538]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 93425000000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [11538]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 93410000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [11538]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 11661000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [11538]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 11661000000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [11538]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 93410000000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
THIGHTROPE ABS AR-1588TN-1
|
Facility
|
IP
|
$973.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$544.88 |
| Max. Negotiated Rate |
$943.81 |
| Rate for Payer: Cash Price |
$583.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$681.10
|
| Rate for Payer: Health Management Network Commercial |
$827.05
|
| Rate for Payer: MDX Hawaii PPO |
$943.81
|
| Rate for Payer: University Health Alliance Commercial |
$544.88
|
|
|
THIGHTROPE ABS AR-1588TN-1
|
Facility
|
OP
|
$973.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$496.23 |
| Max. Negotiated Rate |
$943.81 |
| Rate for Payer: Cash Price |
$583.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$681.10
|
| Rate for Payer: Health Management Network Commercial |
$827.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$612.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$496.23
|
| Rate for Payer: MDX Hawaii PPO |
$943.81
|
| Rate for Payer: University Health Alliance Commercial |
$544.88
|
|
|
THORACIC ENDO TGU262610
|
Facility
|
IP
|
$35,872.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20,088.32 |
| Max. Negotiated Rate |
$34,795.84 |
| Rate for Payer: Cash Price |
$21,523.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25,110.40
|
| Rate for Payer: Health Management Network Commercial |
$30,491.20
|
| Rate for Payer: MDX Hawaii PPO |
$34,795.84
|
| Rate for Payer: University Health Alliance Commercial |
$20,088.32
|
|
|
THORACIC ENDO TGU262610
|
Facility
|
OP
|
$35,872.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$18,294.72 |
| Max. Negotiated Rate |
$34,795.84 |
| Rate for Payer: Cash Price |
$21,523.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25,110.40
|
| Rate for Payer: Health Management Network Commercial |
$30,491.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$22,599.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18,294.72
|
| Rate for Payer: MDX Hawaii PPO |
$34,795.84
|
| Rate for Payer: University Health Alliance Commercial |
$20,088.32
|
|
|
THRD 2.4 X78 HEX 03.507.002
|
Facility
|
IP
|
$1,054.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$895.90 |
| Max. Negotiated Rate |
$1,022.38 |
| Rate for Payer: Cash Price |
$632.40
|
| Rate for Payer: Health Management Network Commercial |
$895.90
|
| Rate for Payer: MDX Hawaii PPO |
$1,022.38
|
|
