Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]

Facility

$1.00

Service Code	NDC 70012000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.76
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.76
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.76
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.76
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.76
Rate for Payer: Ohana Health Plan Medicare	$0.76
Rate for Payer: UnitedHealthcare Medicare	$0.76
Rate for Payer: University Health Alliance Commercial	$0.73

PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]

Facility

$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: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

QUADRASPHERE 20-40uM

Facility

$2,340.00

Hospital Revenue Code	250
Min. Negotiated Rate	$1,170.00
Max. Negotiated Rate	$2,269.80
Rate for Payer: AlohaCare Medicaid	$1,170.00
Rate for Payer: AlohaCare Medicare	$1,778.40
Rate for Payer: Cash Price	$1,404.00
Rate for Payer: Devoted Health Medicare	$1,965.60
Rate for Payer: Hawaii Medical Service Association Medicare	$1,778.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,223.00
Rate for Payer: Health Management Network Commercial	$1,989.00
Rate for Payer: Humana Medicare	$1,778.40
Rate for Payer: Kaiser Permanente Commercial	$2,106.00
Rate for Payer: Kaiser Permanente Medicaid	$1,193.40
Rate for Payer: Kaiser Permanente Medicare	$1,778.40
Rate for Payer: MDX Hawaii PPO	$2,269.80
Rate for Payer: Ohana Health Plan Medicaid	$1,778.40
Rate for Payer: Ohana Health Plan Medicare	$1,778.40
Rate for Payer: UnitedHealthcare Medicaid	$1,404.00
Rate for Payer: UnitedHealthcare Medicare	$1,778.40
Rate for Payer: University Health Alliance Commercial	$1,705.63

QUADRASPHERE 20-40uM

Facility

$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: Kaiser Permanente Commercial	$2,106.00
Rate for Payer: MDX Hawaii PPO	$2,269.80

QUADRASPHERE MICRO 50-100

Facility

$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: Kaiser Permanente Commercial	$2,106.00
Rate for Payer: MDX Hawaii PPO	$2,269.80

QUADRASPHERE MICRO 50-100

Facility

$2,340.00

Hospital Revenue Code	250
Min. Negotiated Rate	$1,170.00
Max. Negotiated Rate	$2,269.80
Rate for Payer: AlohaCare Medicaid	$1,170.00
Rate for Payer: AlohaCare Medicare	$1,778.40
Rate for Payer: Cash Price	$1,404.00
Rate for Payer: Devoted Health Medicare	$1,965.60
Rate for Payer: Hawaii Medical Service Association Medicare	$1,778.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,223.00
Rate for Payer: Health Management Network Commercial	$1,989.00
Rate for Payer: Humana Medicare	$1,778.40
Rate for Payer: Kaiser Permanente Commercial	$2,106.00
Rate for Payer: Kaiser Permanente Medicaid	$1,193.40
Rate for Payer: Kaiser Permanente Medicare	$1,778.40
Rate for Payer: MDX Hawaii PPO	$2,269.80
Rate for Payer: Ohana Health Plan Medicaid	$1,778.40
Rate for Payer: Ohana Health Plan Medicare	$1,778.40
Rate for Payer: UnitedHealthcare Medicaid	$1,404.00
Rate for Payer: UnitedHealthcare Medicare	$1,778.40
Rate for Payer: University Health Alliance Commercial	$1,705.63

QUETIAPINE 100 MG TABLET [21824]

Facility

$20.00

Service Code	NDC 60687034911
Hospital Revenue Code	637
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$19.40
Rate for Payer: AlohaCare Medicaid	$10.00
Rate for Payer: AlohaCare Medicare	$15.20
Rate for Payer: Cash Price	$12.00
Rate for Payer: Devoted Health Medicare	$16.80
Rate for Payer: Hawaii Medical Service Association Medicare	$15.20
Rate for Payer: Hawaii Western Management Group Commercial	$19.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Humana Medicare	$15.20
Rate for Payer: Kaiser Permanente Commercial	$18.00
Rate for Payer: Kaiser Permanente Medicaid	$10.20
Rate for Payer: Kaiser Permanente Medicare	$15.20
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: Ohana Health Plan Medicaid	$15.20
Rate for Payer: Ohana Health Plan Medicare	$15.20
Rate for Payer: UnitedHealthcare Medicare	$15.20
Rate for Payer: University Health Alliance Commercial	$14.58

QUETIAPINE 100 MG TABLET [21824]

Facility

$20.00

Service Code	NDC 60687034901
Hospital Revenue Code	637
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$19.40
Rate for Payer: AlohaCare Medicaid	$10.00
Rate for Payer: AlohaCare Medicare	$15.20
Rate for Payer: Cash Price	$12.00
Rate for Payer: Devoted Health Medicare	$16.80
Rate for Payer: Hawaii Medical Service Association Medicare	$15.20
Rate for Payer: Hawaii Western Management Group Commercial	$19.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Humana Medicare	$15.20
Rate for Payer: Kaiser Permanente Commercial	$18.00
Rate for Payer: Kaiser Permanente Medicaid	$10.20
Rate for Payer: Kaiser Permanente Medicare	$15.20
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: Ohana Health Plan Medicaid	$15.20
Rate for Payer: Ohana Health Plan Medicare	$15.20
Rate for Payer: UnitedHealthcare Medicare	$15.20
Rate for Payer: University Health Alliance Commercial	$14.58

QUETIAPINE 100 MG TABLET [21824]

Facility

$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: Kaiser Permanente Commercial	$18.00
Rate for Payer: MDX Hawaii PPO	$19.40

QUETIAPINE 100 MG TABLET [21824]

Facility

$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: Kaiser Permanente Commercial	$18.00
Rate for Payer: MDX Hawaii PPO	$19.40

QUETIAPINE 200 MG TABLET [21825]

Facility

$31.00

Service Code	NDC 60687036001
Hospital Revenue Code	637
Min. Negotiated Rate	$15.50
Max. Negotiated Rate	$30.07
Rate for Payer: AlohaCare Medicaid	$15.50
Rate for Payer: AlohaCare Medicare	$23.56
Rate for Payer: Cash Price	$18.60
Rate for Payer: Devoted Health Medicare	$26.04
Rate for Payer: Hawaii Medical Service Association Medicare	$23.56
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Humana Medicare	$23.56
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: Kaiser Permanente Medicare	$23.56
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: Ohana Health Plan Medicaid	$23.56
Rate for Payer: Ohana Health Plan Medicare	$23.56
Rate for Payer: UnitedHealthcare Medicare	$23.56
Rate for Payer: University Health Alliance Commercial	$22.60

QUETIAPINE 200 MG TABLET [21825]

Facility

$4.00

Service Code	NDC 00904664161
Hospital Revenue Code	637
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$3.04
Rate for Payer: Cash Price	$2.40
Rate for Payer: Devoted Health Medicare	$3.36
Rate for Payer: Hawaii Medical Service Association Medicare	$3.04
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$3.04
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$3.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$3.04
Rate for Payer: Ohana Health Plan Medicare	$3.04
Rate for Payer: UnitedHealthcare Medicare	$3.04
Rate for Payer: University Health Alliance Commercial	$2.92

QUETIAPINE 200 MG TABLET [21825]

Facility

$31.00

Service Code	NDC 60687036011
Hospital Revenue Code	637
Min. Negotiated Rate	$15.50
Max. Negotiated Rate	$30.07
Rate for Payer: AlohaCare Medicaid	$15.50
Rate for Payer: AlohaCare Medicare	$23.56
Rate for Payer: Cash Price	$18.60
Rate for Payer: Devoted Health Medicare	$26.04
Rate for Payer: Hawaii Medical Service Association Medicare	$23.56
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Humana Medicare	$23.56
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: Kaiser Permanente Medicare	$23.56
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: Ohana Health Plan Medicaid	$23.56
Rate for Payer: Ohana Health Plan Medicare	$23.56
Rate for Payer: UnitedHealthcare Medicare	$23.56
Rate for Payer: University Health Alliance Commercial	$22.60

QUETIAPINE 200 MG TABLET [21825]

Facility

$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: Kaiser Permanente Commercial	$27.90
Rate for Payer: MDX Hawaii PPO	$30.07

QUETIAPINE 200 MG TABLET [21825]

Facility

$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: Kaiser Permanente Commercial	$27.90
Rate for Payer: MDX Hawaii PPO	$30.07

QUETIAPINE 200 MG TABLET [21825]

Facility

$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: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

QUETIAPINE 25 MG TABLET [21823]

Facility

$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: Kaiser Permanente Commercial	$12.60
Rate for Payer: MDX Hawaii PPO	$13.58

QUETIAPINE 25 MG TABLET [21823]

Facility

$14.00

Service Code	NDC 60687032701
Hospital Revenue Code	637
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$13.58
Rate for Payer: AlohaCare Medicaid	$7.00
Rate for Payer: AlohaCare Medicare	$10.64
Rate for Payer: Cash Price	$8.40
Rate for Payer: Devoted Health Medicare	$11.76
Rate for Payer: Hawaii Medical Service Association Medicare	$10.64
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Humana Medicare	$10.64
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: Kaiser Permanente Medicare	$10.64
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: Ohana Health Plan Medicaid	$10.64
Rate for Payer: Ohana Health Plan Medicare	$10.64
Rate for Payer: UnitedHealthcare Medicare	$10.64
Rate for Payer: University Health Alliance Commercial	$10.20

QUETIAPINE 25 MG TABLET [21823]

Facility

$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: Kaiser Permanente Commercial	$12.60
Rate for Payer: MDX Hawaii PPO	$13.58

QUETIAPINE 25 MG TABLET [21823]

Facility

$14.00

Service Code	NDC 60687032711
Hospital Revenue Code	637
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$13.58
Rate for Payer: AlohaCare Medicaid	$7.00
Rate for Payer: AlohaCare Medicare	$10.64
Rate for Payer: Cash Price	$8.40
Rate for Payer: Devoted Health Medicare	$11.76
Rate for Payer: Hawaii Medical Service Association Medicare	$10.64
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Humana Medicare	$10.64
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: Kaiser Permanente Medicare	$10.64
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: Ohana Health Plan Medicaid	$10.64
Rate for Payer: Ohana Health Plan Medicare	$10.64
Rate for Payer: UnitedHealthcare Medicare	$10.64
Rate for Payer: University Health Alliance Commercial	$10.20

QUETIAPINE 300 MG TABLET [29267]

Facility

$41.00

Service Code	NDC 60687037111
Hospital Revenue Code	637
Min. Negotiated Rate	$20.50
Max. Negotiated Rate	$39.77
Rate for Payer: Humana Medicare	$31.16
Rate for Payer: AlohaCare Medicaid	$20.50
Rate for Payer: AlohaCare Medicare	$31.16
Rate for Payer: Cash Price	$24.60
Rate for Payer: Devoted Health Medicare	$34.44
Rate for Payer: Hawaii Medical Service Association Medicare	$31.16
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	$36.90
Rate for Payer: Kaiser Permanente Medicaid	$20.91
Rate for Payer: Kaiser Permanente Medicare	$31.16
Rate for Payer: MDX Hawaii PPO	$39.77
Rate for Payer: Ohana Health Plan Medicaid	$31.16
Rate for Payer: Ohana Health Plan Medicare	$31.16
Rate for Payer: UnitedHealthcare Medicare	$31.16
Rate for Payer: University Health Alliance Commercial	$29.88

QUETIAPINE 300 MG TABLET [29267]

Facility

$41.00

Service Code	NDC 60687037101
Hospital Revenue Code	637
Min. Negotiated Rate	$20.50
Max. Negotiated Rate	$39.77
Rate for Payer: AlohaCare Medicaid	$20.50
Rate for Payer: AlohaCare Medicare	$31.16
Rate for Payer: Cash Price	$24.60
Rate for Payer: Devoted Health Medicare	$34.44
Rate for Payer: Hawaii Medical Service Association Medicare	$31.16
Rate for Payer: Hawaii Western Management Group Commercial	$38.95
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Humana Medicare	$31.16
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: Kaiser Permanente Medicaid	$20.91
Rate for Payer: Kaiser Permanente Medicare	$31.16
Rate for Payer: MDX Hawaii PPO	$39.77
Rate for Payer: Ohana Health Plan Medicaid	$31.16
Rate for Payer: Ohana Health Plan Medicare	$31.16
Rate for Payer: UnitedHealthcare Medicare	$31.16
Rate for Payer: University Health Alliance Commercial	$29.88

QUETIAPINE 300 MG TABLET [29267]

Facility

$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: Kaiser Permanente Commercial	$36.90
Rate for Payer: MDX Hawaii PPO	$39.77

QUETIAPINE 300 MG TABLET [29267]

Facility

$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: Kaiser Permanente Commercial	$36.90
Rate for Payer: MDX Hawaii PPO	$39.77

QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR [96233]

Facility

$40.00

Service Code	NDC 16729010912
Hospital Revenue Code	250
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Kaiser Permanente Commercial	$36.00
Rate for Payer: MDX Hawaii PPO	$38.80

Know your out-of-pocket cost for care.

All Charges