|
PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 70012000000
|
|
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
|
|
|
PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 70012000000
|
|
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
|
|
|
PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 85811000000
|
|
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
|
|
|
PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 85815000000
|
|
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
|
|
|
QUADRASPHERE 20-40uM
|
Facility
|
IP
|
$2,340.00
|
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,989.00 |
| Max. Negotiated Rate |
$2,269.80 |
| Rate for Payer: Cash Price |
$1,404.00
|
| Rate for Payer: Health Management Network Commercial |
$1,989.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,269.80
|
|
|
QUADRASPHERE 20-40uM
|
Facility
|
OP
|
$2,340.00
|
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,193.40 |
| Max. Negotiated Rate |
$2,269.80 |
| Rate for Payer: Cash Price |
$1,404.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,223.00
|
| Rate for Payer: Health Management Network Commercial |
$1,989.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,474.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,193.40
|
| Rate for Payer: MDX Hawaii PPO |
$2,269.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,404.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,705.63
|
|
|
QUADRASPHERE MICRO 50-100
|
Facility
|
OP
|
$2,340.00
|
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,193.40 |
| Max. Negotiated Rate |
$2,269.80 |
| Rate for Payer: Cash Price |
$1,404.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,223.00
|
| Rate for Payer: Health Management Network Commercial |
$1,989.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,474.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,193.40
|
| Rate for Payer: MDX Hawaii PPO |
$2,269.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,404.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,705.63
|
|
|
QUADRASPHERE MICRO 50-100
|
Facility
|
IP
|
$2,340.00
|
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,989.00 |
| Max. Negotiated Rate |
$2,269.80 |
| Rate for Payer: Cash Price |
$1,404.00
|
| Rate for Payer: Health Management Network Commercial |
$1,989.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,269.80
|
|
|
QUETIAPINE 100 MG TABLET [21824]
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 60687034911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
|
|
QUETIAPINE 100 MG TABLET [21824]
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 60687034911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
|
|
QUETIAPINE 100 MG TABLET [21824]
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 60687034901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
|
|
QUETIAPINE 100 MG TABLET [21824]
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 60687034901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
|
|
QUETIAPINE 200 MG TABLET [21825]
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 60687036001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
QUETIAPINE 200 MG TABLET [21825]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904664161
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
QUETIAPINE 200 MG TABLET [21825]
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
NDC 60687036011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.81 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
|
|
QUETIAPINE 200 MG TABLET [21825]
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
NDC 60687036001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.81 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
|
|
QUETIAPINE 200 MG TABLET [21825]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904664161
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
QUETIAPINE 200 MG TABLET [21825]
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 60687036011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
QUETIAPINE 25 MG TABLET [21823]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 60687032701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
QUETIAPINE 25 MG TABLET [21823]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 60687032711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
QUETIAPINE 25 MG TABLET [21823]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 60687032711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.14 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
|
QUETIAPINE 25 MG TABLET [21823]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 60687032701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.14 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
|
QUETIAPINE 300 MG TABLET [29267]
|
Facility
|
IP
|
$41.00
|
|
|
Service Code
|
NDC 60687037111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.85 |
| Max. Negotiated Rate |
$39.77 |
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Health Management Network Commercial |
$34.85
|
| Rate for Payer: MDX Hawaii PPO |
$39.77
|
|
|
QUETIAPINE 300 MG TABLET [29267]
|
Facility
|
OP
|
$41.00
|
|
|
Service Code
|
NDC 60687037101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.91 |
| Max. Negotiated Rate |
$39.77 |
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.95
|
| Rate for Payer: Health Management Network Commercial |
$34.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.83
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.91
|
| Rate for Payer: MDX Hawaii PPO |
$39.77
|
| Rate for Payer: University Health Alliance Commercial |
$29.88
|
|
|
QUETIAPINE 300 MG TABLET [29267]
|
Facility
|
IP
|
$41.00
|
|
|
Service Code
|
NDC 60687037101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.85 |
| Max. Negotiated Rate |
$39.77 |
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Health Management Network Commercial |
$34.85
|
| Rate for Payer: MDX Hawaii PPO |
$39.77
|
|
