Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Testosterone, Free & Total FSI

Facility

$285.00

Service Code	HCPCS 84402
Hospital Charge Code	8118056
Hospital Revenue Code	300
Min. Negotiated Rate	$25.47
Max. Negotiated Rate	$276.45
Rate for Payer: AlohaCare Medicaid	$142.50
Rate for Payer: AlohaCare Medicare	$142.50
Rate for Payer: Cash Price	$185.25
Rate for Payer: Cash Price	$185.25
Rate for Payer: Devoted Health Medicare	$156.75
Rate for Payer: Hawaii Medical Service Association ABD	$35.19
Rate for Payer: Hawaii Medical Service Association Commercial	$31.84
Rate for Payer: Hawaii Medical Service Association Medicare	$142.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$36.95
Rate for Payer: Hawaii Western Management Group Commercial	$25.47
Rate for Payer: Health Management Network Commercial	$242.25
Rate for Payer: Humana Medicare	$142.50
Rate for Payer: Kaiser Permanente Commercial	$256.50
Rate for Payer: Kaiser Permanente Medicaid	$145.35
Rate for Payer: Kaiser Permanente Medicare	$142.50
Rate for Payer: MDX Hawaii PPO	$276.45
Rate for Payer: Ohana Health Plan Medicaid	$142.50
Rate for Payer: Ohana Health Plan Medicare	$142.50
Rate for Payer: UnitedHealthcare Medicaid	$35.19
Rate for Payer: UnitedHealthcare Medicare	$142.50
Rate for Payer: University Health Alliance Commercial	$65.80

Testosterone, Free & Total FSI

Facility

$285.00

Service Code	HCPCS 84402
Hospital Charge Code	8118056
Hospital Revenue Code	300
Min. Negotiated Rate	$242.25
Max. Negotiated Rate	$276.45
Rate for Payer: Cash Price	$185.25
Rate for Payer: Health Management Network Commercial	$242.25
Rate for Payer: Kaiser Permanente Commercial	$256.50
Rate for Payer: MDX Hawaii PPO	$276.45

tetanus/diphtheria/pertussis, acel (Tdap) 0.5ml [HHSC]

Facility

$298.13

Service Code	HCPCS 90715
Hospital Charge Code	2500814
Hospital Revenue Code	636
Min. Negotiated Rate	$38.63
Max. Negotiated Rate	$289.19
Rate for Payer: Kaiser Permanente Medicare	$141.81
Rate for Payer: AlohaCare Medicaid	$149.06
Rate for Payer: AlohaCare Medicaid	$141.81
Rate for Payer: AlohaCare Medicare	$141.81
Rate for Payer: AlohaCare Medicare	$149.06
Rate for Payer: Cash Price	$184.35
Rate for Payer: Cash Price	$184.35
Rate for Payer: Cash Price	$193.78
Rate for Payer: Cash Price	$193.78
Rate for Payer: Devoted Health Medicare	$155.99
Rate for Payer: Devoted Health Medicare	$163.97
Rate for Payer: Hawaii Medical Service Association ABD	$38.63
Rate for Payer: Hawaii Medical Service Association ABD	$38.63
Rate for Payer: Hawaii Medical Service Association Medicare	$141.81
Rate for Payer: Hawaii Medical Service Association Medicare	$149.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$38.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$38.63
Rate for Payer: Hawaii Western Management Group Commercial	$269.44
Rate for Payer: Hawaii Western Management Group Commercial	$283.22
Rate for Payer: Health Management Network Commercial	$241.08
Rate for Payer: Health Management Network Commercial	$253.41
Rate for Payer: Humana Medicare	$141.81
Rate for Payer: Humana Medicare	$149.06
Rate for Payer: Kaiser Permanente Commercial	$268.32
Rate for Payer: Kaiser Permanente Commercial	$255.26
Rate for Payer: Kaiser Permanente Medicaid	$144.65
Rate for Payer: Kaiser Permanente Medicaid	$152.05
Rate for Payer: Kaiser Permanente Medicare	$149.06
Rate for Payer: MDX Hawaii PPO	$275.11
Rate for Payer: MDX Hawaii PPO	$289.19
Rate for Payer: Ohana Health Plan Medicaid	$149.06
Rate for Payer: Ohana Health Plan Medicaid	$141.81
Rate for Payer: Ohana Health Plan Medicare	$141.81
Rate for Payer: Ohana Health Plan Medicare	$149.06
Rate for Payer: UnitedHealthcare Medicaid	$170.17
Rate for Payer: UnitedHealthcare Medicaid	$178.88
Rate for Payer: UnitedHealthcare Medicare	$149.06
Rate for Payer: UnitedHealthcare Medicare	$141.81
Rate for Payer: University Health Alliance Commercial	$158.83
Rate for Payer: University Health Alliance Commercial	$166.95

tetanus/diphtheria/pertussis, acel (Tdap) 0.5ml [HHSC]

Facility

$283.62

Service Code	HCPCS 90715
Hospital Charge Code	2500814
Hospital Revenue Code	250
Min. Negotiated Rate	$241.08
Max. Negotiated Rate	$275.11
Rate for Payer: Cash Price	$184.35
Rate for Payer: Cash Price	$193.78
Rate for Payer: Health Management Network Commercial	$253.41
Rate for Payer: Health Management Network Commercial	$241.08
Rate for Payer: Kaiser Permanente Commercial	$255.26
Rate for Payer: Kaiser Permanente Commercial	$268.32
Rate for Payer: MDX Hawaii PPO	$275.11
Rate for Payer: MDX Hawaii PPO	$289.19

Tetanus IgG Antibody FSI

Facility

$170.00

Service Code	HCPCS 86774
Hospital Charge Code	9960211
Hospital Revenue Code	302
Min. Negotiated Rate	$12.41
Max. Negotiated Rate	$164.90
Rate for Payer: AlohaCare Medicaid	$85.00
Rate for Payer: AlohaCare Medicare	$85.00
Rate for Payer: Cash Price	$110.50
Rate for Payer: Cash Price	$110.50
Rate for Payer: Devoted Health Medicare	$93.50
Rate for Payer: Hawaii Medical Service Association ABD	$12.41
Rate for Payer: Hawaii Medical Service Association Commercial	$18.50
Rate for Payer: Hawaii Medical Service Association Medicare	$85.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.44
Rate for Payer: Hawaii Western Management Group Commercial	$14.80
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: Humana Medicare	$85.00
Rate for Payer: Kaiser Permanente Commercial	$153.00
Rate for Payer: Kaiser Permanente Medicaid	$86.70
Rate for Payer: Kaiser Permanente Medicare	$85.00
Rate for Payer: MDX Hawaii PPO	$164.90
Rate for Payer: Ohana Health Plan Medicaid	$85.00
Rate for Payer: Ohana Health Plan Medicare	$85.00
Rate for Payer: UnitedHealthcare Medicaid	$12.41
Rate for Payer: UnitedHealthcare Medicare	$85.00
Rate for Payer: University Health Alliance Commercial	$38.26

Tetanus IgG Antibody FSI

Facility

$170.00

Service Code	HCPCS 86774
Hospital Charge Code	9960211
Hospital Revenue Code	302
Min. Negotiated Rate	$144.50
Max. Negotiated Rate	$164.90
Rate for Payer: Cash Price	$110.50
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: Kaiser Permanente Commercial	$153.00
Rate for Payer: MDX Hawaii PPO	$164.90

tetanus immune glob 250 unit/1ml syringe [HHSC]

Facility

$1,570.99

Service Code	HCPCS J1670
Hospital Charge Code	2500813
Hospital Revenue Code	250
Min. Negotiated Rate	$1,335.34
Max. Negotiated Rate	$1,523.86
Rate for Payer: Cash Price	$1,021.14
Rate for Payer: Health Management Network Commercial	$1,335.34
Rate for Payer: Kaiser Permanente Commercial	$1,413.89
Rate for Payer: MDX Hawaii PPO	$1,523.86

tetanus immune glob 250 unit/1ml syringe [HHSC]

Facility

$1,570.99

Service Code	HCPCS J1670
Hospital Charge Code	2500813
Hospital Revenue Code	636
Min. Negotiated Rate	$577.05
Max. Negotiated Rate	$1,523.86
Rate for Payer: AlohaCare Medicaid	$785.50
Rate for Payer: AlohaCare Medicare	$785.50
Rate for Payer: Cash Price	$1,021.14
Rate for Payer: Cash Price	$1,021.14
Rate for Payer: Devoted Health Medicare	$864.04
Rate for Payer: Hawaii Medical Service Association ABD	$577.05
Rate for Payer: Hawaii Medical Service Association Commercial	$697.65
Rate for Payer: Hawaii Medical Service Association Medicare	$785.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$577.05
Rate for Payer: Hawaii Western Management Group Commercial	$1,492.44
Rate for Payer: Health Management Network Commercial	$1,335.34
Rate for Payer: Humana Medicare	$785.50
Rate for Payer: Kaiser Permanente Commercial	$1,413.89
Rate for Payer: Kaiser Permanente Medicaid	$801.20
Rate for Payer: Kaiser Permanente Medicare	$785.50
Rate for Payer: MDX Hawaii PPO	$1,523.86
Rate for Payer: Ohana Health Plan Medicaid	$785.50
Rate for Payer: Ohana Health Plan Medicare	$785.50
Rate for Payer: UnitedHealthcare Medicaid	$942.59
Rate for Payer: UnitedHealthcare Medicare	$785.50
Rate for Payer: University Health Alliance Commercial	$1,145.09

.THC Ur Confrm FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8728220
Hospital Revenue Code	301
Min. Negotiated Rate	$47.89
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$692.00
Rate for Payer: Cash Price	$899.60
Rate for Payer: Cash Price	$899.60
Rate for Payer: Devoted Health Medicare	$761.20
Rate for Payer: Hawaii Medical Service Association ABD	$59.38
Rate for Payer: Hawaii Medical Service Association Commercial	$77.67
Rate for Payer: Hawaii Medical Service Association Medicare	$692.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.38
Rate for Payer: Hawaii Western Management Group Commercial	$62.14
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$692.00
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$692.00
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$692.00
Rate for Payer: Ohana Health Plan Medicare	$692.00
Rate for Payer: UnitedHealthcare Medicaid	$47.89
Rate for Payer: UnitedHealthcare Medicare	$692.00
Rate for Payer: University Health Alliance Commercial	$147.65

.THC Ur Confrm FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8728220
Hospital Revenue Code	301
Min. Negotiated Rate	$1,176.40
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$899.60
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48

Theophylline FSI

Facility

$161.00

Service Code	HCPCS 80198
Hospital Charge Code	8128152
Hospital Revenue Code	301
Min. Negotiated Rate	$136.85
Max. Negotiated Rate	$156.17
Rate for Payer: Cash Price	$104.65
Rate for Payer: Health Management Network Commercial	$136.85
Rate for Payer: Kaiser Permanente Commercial	$144.90
Rate for Payer: MDX Hawaii PPO	$156.17

Theophylline FSI

Facility

$161.00

Service Code	HCPCS 80198
Hospital Charge Code	8128152
Hospital Revenue Code	301
Min. Negotiated Rate	$14.14
Max. Negotiated Rate	$156.17
Rate for Payer: AlohaCare Medicaid	$80.50
Rate for Payer: AlohaCare Medicare	$80.50
Rate for Payer: Cash Price	$104.65
Rate for Payer: Cash Price	$104.65
Rate for Payer: Devoted Health Medicare	$88.55
Rate for Payer: Hawaii Medical Service Association ABD	$19.56
Rate for Payer: Hawaii Medical Service Association Commercial	$17.68
Rate for Payer: Hawaii Medical Service Association Medicare	$80.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.54
Rate for Payer: Hawaii Western Management Group Commercial	$14.14
Rate for Payer: Health Management Network Commercial	$136.85
Rate for Payer: Humana Medicare	$80.50
Rate for Payer: Kaiser Permanente Commercial	$144.90
Rate for Payer: Kaiser Permanente Medicaid	$82.11
Rate for Payer: Kaiser Permanente Medicare	$80.50
Rate for Payer: MDX Hawaii PPO	$156.17
Rate for Payer: Ohana Health Plan Medicaid	$80.50
Rate for Payer: Ohana Health Plan Medicare	$80.50
Rate for Payer: UnitedHealthcare Medicaid	$19.56
Rate for Payer: UnitedHealthcare Medicare	$80.50
Rate for Payer: University Health Alliance Commercial	$36.57

Therapeutic Activities Charge

Facility

$307.00

Service Code	HCPCS 97530 GP
Hospital Charge Code	8111693
Hospital Revenue Code	420
Min. Negotiated Rate	$260.95
Max. Negotiated Rate	$297.79
Rate for Payer: Cash Price	$199.55
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$276.30
Rate for Payer: MDX Hawaii PPO	$297.79

Therapeutic Activities Charge

Facility

$307.00

Service Code	HCPCS 97530 GP
Hospital Charge Code	8111693
Hospital Revenue Code	420
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$297.79
Rate for Payer: AlohaCare Medicaid	$153.50
Rate for Payer: AlohaCare Medicare	$153.50
Rate for Payer: Cash Price	$199.55
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$168.85
Rate for Payer: Hawaii Medical Service Association Medicare	$153.50
Rate for Payer: Hawaii Western Management Group Commercial	$291.65
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Humana Medicare	$153.50
Rate for Payer: Kaiser Permanente Commercial	$276.30
Rate for Payer: Kaiser Permanente Medicaid	$156.57
Rate for Payer: Kaiser Permanente Medicare	$153.50
Rate for Payer: MDX Hawaii PPO	$297.79
Rate for Payer: Ohana Health Plan Medicaid	$153.50
Rate for Payer: Ohana Health Plan Medicare	$153.50
Rate for Payer: UnitedHealthcare Medicaid	$18.32
Rate for Payer: UnitedHealthcare Medicare	$153.50
Rate for Payer: University Health Alliance Commercial	$171.92

Therapeutic Activities Charges

Facility

$246.00

Service Code	HCPCS 97530 GP,CQ
Hospital Charge Code	8123836
Hospital Revenue Code	430
Min. Negotiated Rate	$209.10
Max. Negotiated Rate	$238.62
Rate for Payer: Cash Price	$159.90
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: MDX Hawaii PPO	$238.62

Therapeutic Activities Charges

Facility

$246.00

Service Code	HCPCS 97530 GP,CQ
Hospital Charge Code	8123836
Hospital Revenue Code	430
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$238.62
Rate for Payer: AlohaCare Medicaid	$123.00
Rate for Payer: AlohaCare Medicare	$123.00
Rate for Payer: Cash Price	$159.90
Rate for Payer: Cash Price	$159.90
Rate for Payer: Devoted Health Medicare	$135.30
Rate for Payer: Hawaii Medical Service Association Medicare	$123.00
Rate for Payer: Hawaii Western Management Group Commercial	$233.70
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Humana Medicare	$123.00
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: Kaiser Permanente Medicaid	$125.46
Rate for Payer: Kaiser Permanente Medicare	$123.00
Rate for Payer: MDX Hawaii PPO	$238.62
Rate for Payer: Ohana Health Plan Medicaid	$123.00
Rate for Payer: Ohana Health Plan Medicare	$123.00
Rate for Payer: UnitedHealthcare Medicaid	$18.32
Rate for Payer: UnitedHealthcare Medicare	$123.00
Rate for Payer: University Health Alliance Commercial	$137.76

Therapeutic Exercise Charges

Facility

$199.00

Service Code	HCPCS 97110 GP
Hospital Charge Code	8111702
Hospital Revenue Code	420
Min. Negotiated Rate	$169.15
Max. Negotiated Rate	$193.03
Rate for Payer: Cash Price	$129.35
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Kaiser Permanente Commercial	$179.10
Rate for Payer: MDX Hawaii PPO	$193.03

Therapeutic Exercise Charges

Facility

$199.00

Service Code	HCPCS 97110 GP,CQ
Hospital Charge Code	8123834
Hospital Revenue Code	430
Min. Negotiated Rate	$17.65
Max. Negotiated Rate	$193.03
Rate for Payer: AlohaCare Medicaid	$99.50
Rate for Payer: AlohaCare Medicare	$99.50
Rate for Payer: Cash Price	$129.35
Rate for Payer: Cash Price	$129.35
Rate for Payer: Devoted Health Medicare	$109.45
Rate for Payer: Hawaii Medical Service Association Medicare	$99.50
Rate for Payer: Hawaii Western Management Group Commercial	$189.05
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Humana Medicare	$99.50
Rate for Payer: Kaiser Permanente Commercial	$179.10
Rate for Payer: Kaiser Permanente Medicaid	$101.49
Rate for Payer: Kaiser Permanente Medicare	$99.50
Rate for Payer: MDX Hawaii PPO	$193.03
Rate for Payer: Ohana Health Plan Medicaid	$99.50
Rate for Payer: Ohana Health Plan Medicare	$99.50
Rate for Payer: UnitedHealthcare Medicaid	$17.65
Rate for Payer: UnitedHealthcare Medicare	$99.50
Rate for Payer: University Health Alliance Commercial	$111.44

Therapeutic Exercise Charges

Facility

$199.00

Service Code	HCPCS 97110 GP,CQ
Hospital Charge Code	8123834
Hospital Revenue Code	430
Min. Negotiated Rate	$169.15
Max. Negotiated Rate	$193.03
Rate for Payer: Cash Price	$129.35
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Kaiser Permanente Commercial	$179.10
Rate for Payer: MDX Hawaii PPO	$193.03

Therapeutic Exercise Charges

Facility

$199.00

Service Code	HCPCS 97110 GP
Hospital Charge Code	8111702
Hospital Revenue Code	420
Min. Negotiated Rate	$17.65
Max. Negotiated Rate	$193.03
Rate for Payer: AlohaCare Medicaid	$99.50
Rate for Payer: AlohaCare Medicare	$99.50
Rate for Payer: Cash Price	$129.35
Rate for Payer: Cash Price	$129.35
Rate for Payer: Devoted Health Medicare	$109.45
Rate for Payer: Hawaii Medical Service Association Medicare	$99.50
Rate for Payer: Hawaii Western Management Group Commercial	$189.05
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Humana Medicare	$99.50
Rate for Payer: Kaiser Permanente Commercial	$179.10
Rate for Payer: Kaiser Permanente Medicaid	$101.49
Rate for Payer: Kaiser Permanente Medicare	$99.50
Rate for Payer: MDX Hawaii PPO	$193.03
Rate for Payer: Ohana Health Plan Medicaid	$99.50
Rate for Payer: Ohana Health Plan Medicare	$99.50
Rate for Payer: UnitedHealthcare Medicaid	$17.65
Rate for Payer: UnitedHealthcare Medicare	$99.50
Rate for Payer: University Health Alliance Commercial	$111.44

thiamine 100 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00536468001
Hospital Charge Code	2500820
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

thiamine 100 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904719106
Hospital Charge Code	2500820
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

thiamine 100 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 77333093410
Hospital Charge Code	2500820
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

thiamine 100 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00536468001
Hospital Charge Code	2500820
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

thiamine 100 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904054460
Hospital Charge Code	2500820
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

Know your out-of-pocket cost for care.

All Charges