Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]

Facility

$53.00

Service Code	NDC 64380017301
Hospital Revenue Code	250
Min. Negotiated Rate	$45.05
Max. Negotiated Rate	$51.41
Rate for Payer: Cash Price	$31.80
Rate for Payer: Health Management Network Commercial	$45.05
Rate for Payer: Kaiser Permanente Commercial	$47.70
Rate for Payer: MDX Hawaii PPO	$51.41

OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]

Facility

$53.00

Service Code	NDC 64380017302
Hospital Revenue Code	250
Min. Negotiated Rate	$45.05
Max. Negotiated Rate	$51.41
Rate for Payer: Cash Price	$31.80
Rate for Payer: Health Management Network Commercial	$45.05
Rate for Payer: Kaiser Permanente Commercial	$47.70
Rate for Payer: MDX Hawaii PPO	$51.41

OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]

Facility

$107.00

Service Code	HCPCS J2359
Hospital Revenue Code	250
Min. Negotiated Rate	$90.95
Max. Negotiated Rate	$103.79
Rate for Payer: Cash Price	$64.20
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: MDX Hawaii PPO	$103.79

OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]

Facility

$107.00

Service Code	HCPCS J2359
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$103.79
Rate for Payer: AlohaCare Medicaid	$53.50
Rate for Payer: AlohaCare Medicaid	$13.50
Rate for Payer: AlohaCare Medicare	$20.52
Rate for Payer: AlohaCare Medicare	$81.32
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cash Price	$64.20
Rate for Payer: Cash Price	$64.20
Rate for Payer: Cash Price	$16.20
Rate for Payer: Devoted Health Medicare	$89.88
Rate for Payer: Devoted Health Medicare	$22.68
Rate for Payer: Hawaii Medical Service Association ABD	$0.91
Rate for Payer: Hawaii Medical Service Association ABD	$0.91
Rate for Payer: Hawaii Medical Service Association Medicare	$81.32
Rate for Payer: Hawaii Medical Service Association Medicare	$20.52
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.91
Rate for Payer: Hawaii Western Management Group Commercial	$101.65
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Humana Medicare	$81.32
Rate for Payer: Humana Medicare	$20.52
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: Kaiser Permanente Medicaid	$54.57
Rate for Payer: Kaiser Permanente Medicare	$20.52
Rate for Payer: Kaiser Permanente Medicare	$81.32
Rate for Payer: MDX Hawaii PPO	$103.79
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: Ohana Health Plan Medicaid	$20.52
Rate for Payer: Ohana Health Plan Medicaid	$81.32
Rate for Payer: Ohana Health Plan Medicare	$81.32
Rate for Payer: Ohana Health Plan Medicare	$20.52
Rate for Payer: UnitedHealthcare Medicaid	$64.20
Rate for Payer: UnitedHealthcare Medicaid	$16.20
Rate for Payer: UnitedHealthcare Medicare	$81.32
Rate for Payer: UnitedHealthcare Medicare	$20.52
Rate for Payer: University Health Alliance Commercial	$77.99
Rate for Payer: University Health Alliance Commercial	$19.68

OLANZAPINE 10 MG TABLET [17937]

Facility

$51.00

Service Code	NDC 68084074011
Hospital Revenue Code	637
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$49.47
Rate for Payer: AlohaCare Medicaid	$25.50
Rate for Payer: AlohaCare Medicare	$38.76
Rate for Payer: Cash Price	$30.60
Rate for Payer: Devoted Health Medicare	$42.84
Rate for Payer: Hawaii Medical Service Association Medicare	$38.76
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Humana Medicare	$38.76
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: Kaiser Permanente Medicare	$38.76
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: Ohana Health Plan Medicaid	$38.76
Rate for Payer: Ohana Health Plan Medicare	$38.76
Rate for Payer: UnitedHealthcare Medicare	$38.76
Rate for Payer: University Health Alliance Commercial	$37.17

OLANZAPINE 10 MG TABLET [17937]

Facility

$51.00

Service Code	NDC 68084074001
Hospital Revenue Code	250
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$49.47

OLANZAPINE 10 MG TABLET [17937]

Facility

$51.00

Service Code	NDC 68084074011
Hospital Revenue Code	250
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$49.47

OLANZAPINE 10 MG TABLET [17937]

Facility

$51.00

Service Code	NDC 68084074001
Hospital Revenue Code	637
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$49.47
Rate for Payer: AlohaCare Medicaid	$25.50
Rate for Payer: AlohaCare Medicare	$38.76
Rate for Payer: Cash Price	$30.60
Rate for Payer: Devoted Health Medicare	$42.84
Rate for Payer: Hawaii Medical Service Association Medicare	$38.76
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Humana Medicare	$38.76
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: Kaiser Permanente Medicare	$38.76
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: Ohana Health Plan Medicaid	$38.76
Rate for Payer: Ohana Health Plan Medicare	$38.76
Rate for Payer: UnitedHealthcare Medicare	$38.76
Rate for Payer: University Health Alliance Commercial	$37.17

OLANZAPINE 20 MG TABLET [28158]

Facility

$102.00

Service Code	NDC 68084052901
Hospital Revenue Code	250
Min. Negotiated Rate	$86.70
Max. Negotiated Rate	$98.94
Rate for Payer: Cash Price	$61.20
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Kaiser Permanente Commercial	$91.80
Rate for Payer: MDX Hawaii PPO	$98.94

OLANZAPINE 20 MG TABLET [28158]

Facility

$100.00

Service Code	NDC 55111016830
Hospital Revenue Code	250
Min. Negotiated Rate	$85.00
Max. Negotiated Rate	$97.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Kaiser Permanente Commercial	$90.00
Rate for Payer: MDX Hawaii PPO	$97.00

OLANZAPINE 20 MG TABLET [28158]

Facility

$102.00

Service Code	NDC 68084052901
Hospital Revenue Code	637
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$98.94
Rate for Payer: AlohaCare Medicaid	$51.00
Rate for Payer: AlohaCare Medicare	$77.52
Rate for Payer: Cash Price	$61.20
Rate for Payer: Devoted Health Medicare	$85.68
Rate for Payer: Hawaii Medical Service Association Medicare	$77.52
Rate for Payer: Hawaii Western Management Group Commercial	$96.90
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Humana Medicare	$77.52
Rate for Payer: Kaiser Permanente Commercial	$91.80
Rate for Payer: Kaiser Permanente Medicaid	$52.02
Rate for Payer: Kaiser Permanente Medicare	$77.52
Rate for Payer: MDX Hawaii PPO	$98.94
Rate for Payer: Ohana Health Plan Medicaid	$77.52
Rate for Payer: Ohana Health Plan Medicare	$77.52
Rate for Payer: UnitedHealthcare Medicare	$77.52
Rate for Payer: University Health Alliance Commercial	$74.35

OLANZAPINE 20 MG TABLET [28158]

Facility

$100.00

Service Code	NDC 55111016830
Hospital Revenue Code	637
Min. Negotiated Rate	$50.00
Max. Negotiated Rate	$97.00
Rate for Payer: AlohaCare Medicaid	$50.00
Rate for Payer: AlohaCare Medicare	$76.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Devoted Health Medicare	$84.00
Rate for Payer: Hawaii Medical Service Association Medicare	$76.00
Rate for Payer: Hawaii Western Management Group Commercial	$95.00
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Humana Medicare	$76.00
Rate for Payer: Kaiser Permanente Commercial	$90.00
Rate for Payer: Kaiser Permanente Medicaid	$51.00
Rate for Payer: Kaiser Permanente Medicare	$76.00
Rate for Payer: MDX Hawaii PPO	$97.00
Rate for Payer: Ohana Health Plan Medicaid	$76.00
Rate for Payer: Ohana Health Plan Medicare	$76.00
Rate for Payer: UnitedHealthcare Medicare	$76.00
Rate for Payer: University Health Alliance Commercial	$72.89

OLANZAPINE 20 MG TABLET [28158]

Facility

$102.00

Service Code	NDC 68084052911
Hospital Revenue Code	637
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$98.94
Rate for Payer: AlohaCare Medicaid	$51.00
Rate for Payer: AlohaCare Medicare	$77.52
Rate for Payer: Cash Price	$61.20
Rate for Payer: Devoted Health Medicare	$85.68
Rate for Payer: Hawaii Medical Service Association Medicare	$77.52
Rate for Payer: Hawaii Western Management Group Commercial	$96.90
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Humana Medicare	$77.52
Rate for Payer: Kaiser Permanente Commercial	$91.80
Rate for Payer: Kaiser Permanente Medicaid	$52.02
Rate for Payer: Kaiser Permanente Medicare	$77.52
Rate for Payer: MDX Hawaii PPO	$98.94
Rate for Payer: Ohana Health Plan Medicaid	$77.52
Rate for Payer: Ohana Health Plan Medicare	$77.52
Rate for Payer: UnitedHealthcare Medicare	$77.52
Rate for Payer: University Health Alliance Commercial	$74.35

OLANZAPINE 20 MG TABLET [28158]

Facility

$102.00

Service Code	NDC 68084052911
Hospital Revenue Code	250
Min. Negotiated Rate	$86.70
Max. Negotiated Rate	$98.94
Rate for Payer: Cash Price	$61.20
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Kaiser Permanente Commercial	$91.80
Rate for Payer: MDX Hawaii PPO	$98.94

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$28.00

Service Code	NDC 60505311000
Hospital Revenue Code	250
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: MDX Hawaii PPO	$27.16

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$28.00

Service Code	NDC 60505311000
Hospital Revenue Code	637
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$27.16
Rate for Payer: AlohaCare Medicaid	$14.00
Rate for Payer: AlohaCare Medicare	$21.28
Rate for Payer: Cash Price	$16.80
Rate for Payer: Devoted Health Medicare	$23.52
Rate for Payer: Hawaii Medical Service Association Medicare	$21.28
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Humana Medicare	$21.28
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: Kaiser Permanente Medicare	$21.28
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: Ohana Health Plan Medicaid	$21.28
Rate for Payer: Ohana Health Plan Medicare	$21.28
Rate for Payer: UnitedHealthcare Medicare	$21.28
Rate for Payer: University Health Alliance Commercial	$20.41

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$36.00

Service Code	NDC 64380017201
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$36.00

Service Code	NDC 64380017201
Hospital Revenue Code	637
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$34.92
Rate for Payer: AlohaCare Medicaid	$18.00
Rate for Payer: AlohaCare Medicare	$27.36
Rate for Payer: Cash Price	$21.60
Rate for Payer: Devoted Health Medicare	$30.24
Rate for Payer: Hawaii Medical Service Association Medicare	$27.36
Rate for Payer: Hawaii Western Management Group Commercial	$34.20
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Humana Medicare	$27.36
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: Kaiser Permanente Medicare	$27.36
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: Ohana Health Plan Medicaid	$27.36
Rate for Payer: Ohana Health Plan Medicare	$27.36
Rate for Payer: UnitedHealthcare Medicare	$27.36
Rate for Payer: University Health Alliance Commercial	$26.24

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$36.00

Service Code	NDC 64380017202
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$36.00

Service Code	NDC 64380017202
Hospital Revenue Code	637
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$34.92
Rate for Payer: AlohaCare Medicaid	$18.00
Rate for Payer: AlohaCare Medicare	$27.36
Rate for Payer: Cash Price	$21.60
Rate for Payer: Devoted Health Medicare	$30.24
Rate for Payer: Hawaii Medical Service Association Medicare	$27.36
Rate for Payer: Hawaii Western Management Group Commercial	$34.20
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Humana Medicare	$27.36
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: Kaiser Permanente Medicare	$27.36
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: Ohana Health Plan Medicaid	$27.36
Rate for Payer: Ohana Health Plan Medicare	$27.36
Rate for Payer: UnitedHealthcare Medicare	$27.36
Rate for Payer: University Health Alliance Commercial	$26.24

OLANZAPINE 5 MG TABLET [17936]

Facility

$34.00

Service Code	NDC 60505311100
Hospital Revenue Code	637
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$32.98
Rate for Payer: AlohaCare Medicaid	$17.00
Rate for Payer: AlohaCare Medicare	$25.84
Rate for Payer: Cash Price	$20.40
Rate for Payer: Devoted Health Medicare	$28.56
Rate for Payer: Hawaii Medical Service Association Medicare	$25.84
Rate for Payer: Hawaii Western Management Group Commercial	$32.30
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Humana Medicare	$25.84
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: Kaiser Permanente Medicare	$25.84
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: Ohana Health Plan Medicaid	$25.84
Rate for Payer: Ohana Health Plan Medicare	$25.84
Rate for Payer: UnitedHealthcare Medicare	$25.84
Rate for Payer: University Health Alliance Commercial	$24.78

OLANZAPINE 5 MG TABLET [17936]

Facility

$33.00

Service Code	NDC 68084072301
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: MDX Hawaii PPO	$32.01

OLANZAPINE 5 MG TABLET [17936]

Facility

$34.00

Service Code	NDC 60505311100
Hospital Revenue Code	250
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$20.40
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$32.98

OLANZAPINE 5 MG TABLET [17936]

Facility

$33.00

Service Code	NDC 68084072301
Hospital Revenue Code	637
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$25.08
Rate for Payer: Cash Price	$19.80
Rate for Payer: Devoted Health Medicare	$27.72
Rate for Payer: Hawaii Medical Service Association Medicare	$25.08
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$25.08
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$25.08
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$25.08
Rate for Payer: Ohana Health Plan Medicare	$25.08
Rate for Payer: UnitedHealthcare Medicare	$25.08
Rate for Payer: University Health Alliance Commercial	$24.05

OLMESARTAN 20 MG TABLET [32762]

Facility

$21.00

Service Code	NDC 68462043730
Hospital Revenue Code	250
Min. Negotiated Rate	$17.85
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: MDX Hawaii PPO	$20.37

Know your out-of-pocket cost for care.

All Charges