Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

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

Facility

$40.00

Service Code	NDC 68001059906
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

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

Facility

$40.00

Service Code	NDC 16729010912
Hospital Revenue Code	637
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$38.80
Rate for Payer: AlohaCare Medicaid	$20.00
Rate for Payer: AlohaCare Medicare	$30.40
Rate for Payer: Cash Price	$24.00
Rate for Payer: Devoted Health Medicare	$33.60
Rate for Payer: Hawaii Medical Service Association Medicare	$30.40
Rate for Payer: Hawaii Western Management Group Commercial	$38.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Humana Medicare	$30.40
Rate for Payer: Kaiser Permanente Commercial	$36.00
Rate for Payer: Kaiser Permanente Medicaid	$20.40
Rate for Payer: Kaiser Permanente Medicare	$30.40
Rate for Payer: MDX Hawaii PPO	$38.80
Rate for Payer: Ohana Health Plan Medicaid	$30.40
Rate for Payer: Ohana Health Plan Medicare	$30.40
Rate for Payer: UnitedHealthcare Medicare	$30.40
Rate for Payer: University Health Alliance Commercial	$29.16

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

Facility

$40.00

Service Code	NDC 68001059906
Hospital Revenue Code	637
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$38.80
Rate for Payer: AlohaCare Medicaid	$20.00
Rate for Payer: AlohaCare Medicare	$30.40
Rate for Payer: Cash Price	$24.00
Rate for Payer: Devoted Health Medicare	$33.60
Rate for Payer: Hawaii Medical Service Association Medicare	$30.40
Rate for Payer: Hawaii Western Management Group Commercial	$38.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Humana Medicare	$30.40
Rate for Payer: Kaiser Permanente Commercial	$36.00
Rate for Payer: Kaiser Permanente Medicaid	$20.40
Rate for Payer: Kaiser Permanente Medicare	$30.40
Rate for Payer: MDX Hawaii PPO	$38.80
Rate for Payer: Ohana Health Plan Medicaid	$30.40
Rate for Payer: Ohana Health Plan Medicare	$30.40
Rate for Payer: UnitedHealthcare Medicare	$30.40
Rate for Payer: University Health Alliance Commercial	$29.16

QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR [82089]

Facility

$44.00

Service Code	NDC 68001060006
Hospital Revenue Code	250
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$42.68
Rate for Payer: Cash Price	$26.40
Rate for Payer: Health Management Network Commercial	$37.40
Rate for Payer: Kaiser Permanente Commercial	$39.60
Rate for Payer: MDX Hawaii PPO	$42.68

QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR [82089]

Facility

$5.00

Service Code	NDC 00904680361
Hospital Revenue Code	637
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$3.80
Rate for Payer: Cash Price	$3.00
Rate for Payer: Devoted Health Medicare	$4.20
Rate for Payer: Hawaii Medical Service Association Medicare	$3.80
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$3.80
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$3.80
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$3.80
Rate for Payer: Ohana Health Plan Medicare	$3.80
Rate for Payer: UnitedHealthcare Medicare	$3.80
Rate for Payer: University Health Alliance Commercial	$3.64

QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR [82089]

Facility

$44.00

Service Code	NDC 68001060006
Hospital Revenue Code	637
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$42.68
Rate for Payer: AlohaCare Medicaid	$22.00
Rate for Payer: AlohaCare Medicare	$33.44
Rate for Payer: Cash Price	$26.40
Rate for Payer: Devoted Health Medicare	$36.96
Rate for Payer: Hawaii Medical Service Association Medicare	$33.44
Rate for Payer: Hawaii Western Management Group Commercial	$41.80
Rate for Payer: Health Management Network Commercial	$37.40
Rate for Payer: Humana Medicare	$33.44
Rate for Payer: Kaiser Permanente Commercial	$39.60
Rate for Payer: Kaiser Permanente Medicaid	$22.44
Rate for Payer: Kaiser Permanente Medicare	$33.44
Rate for Payer: MDX Hawaii PPO	$42.68
Rate for Payer: Ohana Health Plan Medicaid	$33.44
Rate for Payer: Ohana Health Plan Medicare	$33.44
Rate for Payer: UnitedHealthcare Medicare	$33.44
Rate for Payer: University Health Alliance Commercial	$32.07

QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR [82089]

Facility

$44.00

Service Code	NDC 68001051306
Hospital Revenue Code	637
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$42.68
Rate for Payer: AlohaCare Medicaid	$22.00
Rate for Payer: AlohaCare Medicare	$33.44
Rate for Payer: Cash Price	$26.40
Rate for Payer: Devoted Health Medicare	$36.96
Rate for Payer: Hawaii Medical Service Association Medicare	$33.44
Rate for Payer: Hawaii Western Management Group Commercial	$41.80
Rate for Payer: Health Management Network Commercial	$37.40
Rate for Payer: Humana Medicare	$33.44
Rate for Payer: Kaiser Permanente Commercial	$39.60
Rate for Payer: Kaiser Permanente Medicaid	$22.44
Rate for Payer: Kaiser Permanente Medicare	$33.44
Rate for Payer: MDX Hawaii PPO	$42.68
Rate for Payer: Ohana Health Plan Medicaid	$33.44
Rate for Payer: Ohana Health Plan Medicare	$33.44
Rate for Payer: UnitedHealthcare Medicare	$33.44
Rate for Payer: University Health Alliance Commercial	$32.07

QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR [82089]

Facility

$5.00

Service Code	NDC 00904680361
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR [82089]

Facility

$44.00

Service Code	NDC 68001051306
Hospital Revenue Code	250
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$42.68
Rate for Payer: Cash Price	$26.40
Rate for Payer: Health Management Network Commercial	$37.40
Rate for Payer: Kaiser Permanente Commercial	$39.60
Rate for Payer: MDX Hawaii PPO	$42.68

QUETIAPINE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [95676]

Facility

$27.00

Service Code	NDC 68001051106
Hospital Revenue Code	250
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19

QUETIAPINE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [95676]

Facility

$4.00

Service Code	NDC 00904680161
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 ER 50 MG TABLET,EXTENDED RELEASE 24 HR [95676]

Facility

$27.00

Service Code	NDC 29300030816
Hospital Revenue Code	250
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19

QUETIAPINE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [95676]

Facility

$4.00

Service Code	NDC 00904680161
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 ER 50 MG TABLET,EXTENDED RELEASE 24 HR [95676]

Facility

$27.00

Service Code	NDC 29300030816
Hospital Revenue Code	637
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$26.19
Rate for Payer: AlohaCare Medicaid	$13.50
Rate for Payer: AlohaCare Medicare	$20.52
Rate for Payer: Cash Price	$16.20
Rate for Payer: Devoted Health Medicare	$22.68
Rate for Payer: Hawaii Medical Service Association Medicare	$20.52
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Humana Medicare	$20.52
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: Kaiser Permanente Medicare	$20.52
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: Ohana Health Plan Medicaid	$20.52
Rate for Payer: Ohana Health Plan Medicare	$20.52
Rate for Payer: UnitedHealthcare Medicare	$20.52
Rate for Payer: University Health Alliance Commercial	$19.68

QUETIAPINE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [95676]

Facility

$27.00

Service Code	NDC 68001051106
Hospital Revenue Code	637
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$26.19
Rate for Payer: AlohaCare Medicaid	$13.50
Rate for Payer: AlohaCare Medicare	$20.52
Rate for Payer: Cash Price	$16.20
Rate for Payer: Devoted Health Medicare	$22.68
Rate for Payer: Hawaii Medical Service Association Medicare	$20.52
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Humana Medicare	$20.52
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: Kaiser Permanente Medicare	$20.52
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: Ohana Health Plan Medicaid	$20.52
Rate for Payer: Ohana Health Plan Medicare	$20.52
Rate for Payer: UnitedHealthcare Medicare	$20.52
Rate for Payer: University Health Alliance Commercial	$19.68

QUICKANCHOR PLUS #3/0 212843

Facility

$2,133.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,066.50
Max. Negotiated Rate	$2,069.01
Rate for Payer: AlohaCare Medicaid	$1,066.50
Rate for Payer: AlohaCare Medicare	$1,621.08
Rate for Payer: Cash Price	$1,279.80
Rate for Payer: Devoted Health Medicare	$1,791.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1,621.08
Rate for Payer: Hawaii Western Management Group Commercial	$1,493.10
Rate for Payer: Health Management Network Commercial	$1,813.05
Rate for Payer: Humana Medicare	$1,621.08
Rate for Payer: Kaiser Permanente Commercial	$1,919.70
Rate for Payer: Kaiser Permanente Medicaid	$1,087.83
Rate for Payer: Kaiser Permanente Medicare	$1,621.08
Rate for Payer: MDX Hawaii PPO	$2,069.01
Rate for Payer: Ohana Health Plan Medicaid	$1,621.08
Rate for Payer: Ohana Health Plan Medicare	$1,621.08
Rate for Payer: UnitedHealthcare Medicare	$1,621.08
Rate for Payer: University Health Alliance Commercial	$1,194.48

QUICKANCHOR PLUS #3/0 212843

Facility

$2,133.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,194.48
Max. Negotiated Rate	$2,069.01
Rate for Payer: Cash Price	$1,279.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,493.10
Rate for Payer: Health Management Network Commercial	$1,813.05
Rate for Payer: Kaiser Permanente Commercial	$1,919.70
Rate for Payer: MDX Hawaii PPO	$2,069.01
Rate for Payer: University Health Alliance Commercial	$1,194.48

QUILL 0, CT-2 12" VLP-4135

Facility

$22.00

Hospital Revenue Code	272
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: MDX Hawaii PPO	$21.34

QUILL 0, CT-2 12" VLP-4135

Facility

$22.00

Hospital Revenue Code	272
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$21.34
Rate for Payer: AlohaCare Medicaid	$11.00
Rate for Payer: AlohaCare Medicare	$16.72
Rate for Payer: Cash Price	$13.20
Rate for Payer: Devoted Health Medicare	$18.48
Rate for Payer: Hawaii Medical Service Association Medicare	$16.72
Rate for Payer: Hawaii Western Management Group Commercial	$20.90
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Humana Medicare	$16.72
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: Kaiser Permanente Medicaid	$11.22
Rate for Payer: Kaiser Permanente Medicare	$16.72
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: Ohana Health Plan Medicaid	$16.72
Rate for Payer: Ohana Health Plan Medicare	$16.72
Rate for Payer: UnitedHealthcare Medicare	$16.72
Rate for Payer: University Health Alliance Commercial	$16.04

QUILL 0, CT-2 9" VLP-4147

Facility

$124.00

Hospital Revenue Code	272
Min. Negotiated Rate	$105.40
Max. Negotiated Rate	$120.28
Rate for Payer: Cash Price	$74.40
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: MDX Hawaii PPO	$120.28

QUILL 0, CT-2 9" VLP-4147

Facility

$124.00

Hospital Revenue Code	272
Min. Negotiated Rate	$62.00
Max. Negotiated Rate	$120.28
Rate for Payer: AlohaCare Medicaid	$62.00
Rate for Payer: AlohaCare Medicare	$94.24
Rate for Payer: Cash Price	$74.40
Rate for Payer: Devoted Health Medicare	$104.16
Rate for Payer: Hawaii Medical Service Association Medicare	$94.24
Rate for Payer: Hawaii Western Management Group Commercial	$117.80
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Humana Medicare	$94.24
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: Kaiser Permanente Medicaid	$63.24
Rate for Payer: Kaiser Permanente Medicare	$94.24
Rate for Payer: MDX Hawaii PPO	$120.28
Rate for Payer: Ohana Health Plan Medicaid	$94.24
Rate for Payer: Ohana Health Plan Medicare	$94.24
Rate for Payer: UnitedHealthcare Medicare	$94.24
Rate for Payer: University Health Alliance Commercial	$90.38

QUINTON TUNNELER 8888415679

Facility

$621.00

Hospital Revenue Code	272
Min. Negotiated Rate	$527.85
Max. Negotiated Rate	$602.37
Rate for Payer: Cash Price	$372.60
Rate for Payer: Health Management Network Commercial	$527.85
Rate for Payer: Kaiser Permanente Commercial	$558.90
Rate for Payer: MDX Hawaii PPO	$602.37

QUINTON TUNNELER 8888415679

Facility

$621.00

Hospital Revenue Code	272
Min. Negotiated Rate	$310.50
Max. Negotiated Rate	$602.37
Rate for Payer: AlohaCare Medicaid	$310.50
Rate for Payer: AlohaCare Medicare	$471.96
Rate for Payer: Cash Price	$372.60
Rate for Payer: Devoted Health Medicare	$521.64
Rate for Payer: Hawaii Medical Service Association Medicare	$471.96
Rate for Payer: Hawaii Western Management Group Commercial	$589.95
Rate for Payer: Health Management Network Commercial	$527.85
Rate for Payer: Humana Medicare	$471.96
Rate for Payer: Kaiser Permanente Commercial	$558.90
Rate for Payer: Kaiser Permanente Medicaid	$316.71
Rate for Payer: Kaiser Permanente Medicare	$471.96
Rate for Payer: MDX Hawaii PPO	$602.37
Rate for Payer: Ohana Health Plan Medicaid	$471.96
Rate for Payer: Ohana Health Plan Medicare	$471.96
Rate for Payer: UnitedHealthcare Medicare	$471.96
Rate for Payer: University Health Alliance Commercial	$452.65

RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION [113082]

Facility

$9.00

Service Code	NDC 00487278401
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION [113082]

Facility

$9.00

Service Code	NDC 00487590199
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

Know your out-of-pocket cost for care.

All Charges