Kau Hospital

All Charges

Charge

Type

Setting

Price

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 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 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

$31.00

Service Code	NDC 60687036011
Hospital Revenue Code	637
Min. Negotiated Rate	$9.61
Max. Negotiated Rate	$30.07
Rate for Payer: AlohaCare Medicaid	$15.50
Rate for Payer: AlohaCare Medicare	$9.61
Rate for Payer: Cash Price	$18.60
Rate for Payer: Devoted Health Medicare	$10.54
Rate for Payer: Hawaii Medical Service Association Medicare	$9.61
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Humana Medicare	$9.61
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: Kaiser Permanente Medicare	$9.61
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: Ohana Health Plan Medicaid	$9.61
Rate for Payer: Ohana Health Plan Medicare	$9.61
Rate for Payer: UnitedHealthcare Medicare	$9.61
Rate for Payer: University Health Alliance Commercial	$22.60

QUETIAPINE 200 MG TABLET [21825]

Facility

$31.00

Service Code	NDC 60687036001
Hospital Revenue Code	637
Min. Negotiated Rate	$9.61
Max. Negotiated Rate	$30.07
Rate for Payer: AlohaCare Medicaid	$15.50
Rate for Payer: AlohaCare Medicare	$9.61
Rate for Payer: Cash Price	$18.60
Rate for Payer: Devoted Health Medicare	$10.54
Rate for Payer: Hawaii Medical Service Association Medicare	$9.61
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Humana Medicare	$9.61
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: Kaiser Permanente Medicare	$9.61
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: Ohana Health Plan Medicaid	$9.61
Rate for Payer: Ohana Health Plan Medicare	$9.61
Rate for Payer: UnitedHealthcare Medicare	$9.61
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	$1.24
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$1.24
Rate for Payer: Cash Price	$2.40
Rate for Payer: Devoted Health Medicare	$1.36
Rate for Payer: Hawaii Medical Service Association Medicare	$1.24
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$1.24
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$1.24
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$1.24
Rate for Payer: Ohana Health Plan Medicare	$1.24
Rate for Payer: UnitedHealthcare Medicare	$1.24
Rate for Payer: University Health Alliance Commercial	$2.92

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 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	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	$4.34
Max. Negotiated Rate	$13.58
Rate for Payer: AlohaCare Medicaid	$7.00
Rate for Payer: AlohaCare Medicare	$4.34
Rate for Payer: Cash Price	$8.40
Rate for Payer: Devoted Health Medicare	$4.76
Rate for Payer: Hawaii Medical Service Association Medicare	$4.34
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Humana Medicare	$4.34
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: Kaiser Permanente Medicare	$4.34
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: Ohana Health Plan Medicaid	$4.34
Rate for Payer: Ohana Health Plan Medicare	$4.34
Rate for Payer: UnitedHealthcare Medicare	$4.34
Rate for Payer: University Health Alliance Commercial	$10.20

QUETIAPINE 25 MG TABLET [21823]

Facility

$14.00

Service Code	NDC 60687032701
Hospital Revenue Code	637
Min. Negotiated Rate	$4.34
Max. Negotiated Rate	$13.58
Rate for Payer: AlohaCare Medicaid	$7.00
Rate for Payer: AlohaCare Medicare	$4.34
Rate for Payer: Cash Price	$8.40
Rate for Payer: Devoted Health Medicare	$4.76
Rate for Payer: Hawaii Medical Service Association Medicare	$4.34
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Humana Medicare	$4.34
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: Kaiser Permanente Medicare	$4.34
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: Ohana Health Plan Medicaid	$4.34
Rate for Payer: Ohana Health Plan Medicare	$4.34
Rate for Payer: UnitedHealthcare Medicare	$4.34
Rate for Payer: University Health Alliance Commercial	$10.20

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	637
Min. Negotiated Rate	$12.71
Max. Negotiated Rate	$39.77
Rate for Payer: AlohaCare Medicaid	$20.50
Rate for Payer: AlohaCare Medicare	$12.71
Rate for Payer: Cash Price	$24.60
Rate for Payer: Devoted Health Medicare	$13.94
Rate for Payer: Hawaii Medical Service Association Medicare	$12.71
Rate for Payer: Hawaii Western Management Group Commercial	$38.95
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Humana Medicare	$12.71
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: Kaiser Permanente Medicaid	$20.91
Rate for Payer: Kaiser Permanente Medicare	$12.71
Rate for Payer: MDX Hawaii PPO	$39.77
Rate for Payer: Ohana Health Plan Medicaid	$12.71
Rate for Payer: Ohana Health Plan Medicare	$12.71
Rate for Payer: UnitedHealthcare Medicare	$12.71
Rate for Payer: University Health Alliance Commercial	$29.88

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 300 MG TABLET [29267]

Facility

$41.00

Service Code	NDC 60687037101
Hospital Revenue Code	637
Min. Negotiated Rate	$12.71
Max. Negotiated Rate	$39.77
Rate for Payer: AlohaCare Medicaid	$20.50
Rate for Payer: AlohaCare Medicare	$12.71
Rate for Payer: Cash Price	$24.60
Rate for Payer: Devoted Health Medicare	$13.94
Rate for Payer: Hawaii Medical Service Association Medicare	$12.71
Rate for Payer: Hawaii Western Management Group Commercial	$38.95
Rate for Payer: Health Management Network Commercial	$34.85
Rate for Payer: Humana Medicare	$12.71
Rate for Payer: Kaiser Permanente Commercial	$36.90
Rate for Payer: Kaiser Permanente Medicaid	$20.91
Rate for Payer: Kaiser Permanente Medicare	$12.71
Rate for Payer: MDX Hawaii PPO	$39.77
Rate for Payer: Ohana Health Plan Medicaid	$12.71
Rate for Payer: Ohana Health Plan Medicare	$12.71
Rate for Payer: UnitedHealthcare Medicare	$12.71
Rate for Payer: University Health Alliance Commercial	$29.88

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

Facility

$40.00

Service Code	NDC 68001059906
Hospital Revenue Code	637
Min. Negotiated Rate	$12.40
Max. Negotiated Rate	$38.80
Rate for Payer: AlohaCare Medicaid	$20.00
Rate for Payer: AlohaCare Medicare	$12.40
Rate for Payer: Cash Price	$24.00
Rate for Payer: Devoted Health Medicare	$13.60
Rate for Payer: Hawaii Medical Service Association Medicare	$12.40
Rate for Payer: Hawaii Western Management Group Commercial	$38.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Humana Medicare	$12.40
Rate for Payer: Kaiser Permanente Commercial	$36.00
Rate for Payer: Kaiser Permanente Medicaid	$20.40
Rate for Payer: Kaiser Permanente Medicare	$12.40
Rate for Payer: MDX Hawaii PPO	$38.80
Rate for Payer: Ohana Health Plan Medicaid	$12.40
Rate for Payer: Ohana Health Plan Medicare	$12.40
Rate for Payer: UnitedHealthcare Medicare	$12.40
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	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	$12.40
Max. Negotiated Rate	$38.80
Rate for Payer: AlohaCare Medicaid	$20.00
Rate for Payer: AlohaCare Medicare	$12.40
Rate for Payer: Cash Price	$24.00
Rate for Payer: Devoted Health Medicare	$13.60
Rate for Payer: Hawaii Medical Service Association Medicare	$12.40
Rate for Payer: Hawaii Western Management Group Commercial	$38.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Humana Medicare	$12.40
Rate for Payer: Kaiser Permanente Commercial	$36.00
Rate for Payer: Kaiser Permanente Medicaid	$20.40
Rate for Payer: Kaiser Permanente Medicare	$12.40
Rate for Payer: MDX Hawaii PPO	$38.80
Rate for Payer: Ohana Health Plan Medicaid	$12.40
Rate for Payer: Ohana Health Plan Medicare	$12.40
Rate for Payer: UnitedHealthcare Medicare	$12.40
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 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

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 200 MG TABLET,EXTENDED RELEASE 24 HR [82089]

Facility

$5.00

Service Code	NDC 00904680361
Hospital Revenue Code	637
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$1.55
Rate for Payer: Cash Price	$3.00
Rate for Payer: Devoted Health Medicare	$1.70
Rate for Payer: Hawaii Medical Service Association Medicare	$1.55
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$1.55
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$1.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$1.55
Rate for Payer: Ohana Health Plan Medicare	$1.55
Rate for Payer: UnitedHealthcare Medicare	$1.55
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 68001051306
Hospital Revenue Code	637
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$42.68
Rate for Payer: AlohaCare Medicaid	$22.00
Rate for Payer: AlohaCare Medicare	$13.64
Rate for Payer: Cash Price	$26.40
Rate for Payer: Devoted Health Medicare	$14.96
Rate for Payer: Hawaii Medical Service Association Medicare	$13.64
Rate for Payer: Hawaii Western Management Group Commercial	$41.80
Rate for Payer: Health Management Network Commercial	$37.40
Rate for Payer: Humana Medicare	$13.64
Rate for Payer: Kaiser Permanente Commercial	$39.60
Rate for Payer: Kaiser Permanente Medicaid	$22.44
Rate for Payer: Kaiser Permanente Medicare	$13.64
Rate for Payer: MDX Hawaii PPO	$42.68
Rate for Payer: Ohana Health Plan Medicaid	$13.64
Rate for Payer: Ohana Health Plan Medicare	$13.64
Rate for Payer: UnitedHealthcare Medicare	$13.64
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 68001060006
Hospital Revenue Code	637
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$42.68
Rate for Payer: AlohaCare Medicaid	$22.00
Rate for Payer: AlohaCare Medicare	$13.64
Rate for Payer: Cash Price	$26.40
Rate for Payer: Devoted Health Medicare	$14.96
Rate for Payer: Hawaii Medical Service Association Medicare	$13.64
Rate for Payer: Hawaii Western Management Group Commercial	$41.80
Rate for Payer: Health Management Network Commercial	$37.40
Rate for Payer: Humana Medicare	$13.64
Rate for Payer: Kaiser Permanente Commercial	$39.60
Rate for Payer: Kaiser Permanente Medicaid	$22.44
Rate for Payer: Kaiser Permanente Medicare	$13.64
Rate for Payer: MDX Hawaii PPO	$42.68
Rate for Payer: Ohana Health Plan Medicaid	$13.64
Rate for Payer: Ohana Health Plan Medicare	$13.64
Rate for Payer: UnitedHealthcare Medicare	$13.64
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 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

Know your out-of-pocket cost for care.

All Charges