Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

QCKFIX SCRW,TI,CANN ST,CANC.,4.0X 50MM

Facility

$346.00

Service Code	HCPCS C1713
Hospital Charge Code	12953319
Hospital Revenue Code	278
Min. Negotiated Rate	$173.00
Max. Negotiated Rate	$335.62
Rate for Payer: AlohaCare Medicaid	$173.00
Rate for Payer: AlohaCare Medicare	$173.00
Rate for Payer: Cash Price	$224.90
Rate for Payer: Devoted Health Medicare	$190.30
Rate for Payer: Hawaii Medical Service Association Medicare	$173.00
Rate for Payer: Hawaii Western Management Group Commercial	$242.20
Rate for Payer: Health Management Network Commercial	$294.10
Rate for Payer: Humana Medicare	$173.00
Rate for Payer: Kaiser Permanente Commercial	$311.40
Rate for Payer: Kaiser Permanente Medicaid	$176.46
Rate for Payer: Kaiser Permanente Medicare	$173.00
Rate for Payer: MDX Hawaii PPO	$335.62
Rate for Payer: Ohana Health Plan Medicaid	$173.00
Rate for Payer: Ohana Health Plan Medicare	$173.00
Rate for Payer: UnitedHealthcare Medicare	$173.00
Rate for Payer: University Health Alliance Commercial	$193.76

QuantF TB Gold Plus FSI

Facility

$392.00

Service Code	HCPCS 86480
Hospital Charge Code	8225274
Hospital Revenue Code	300
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$254.80
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: MDX Hawaii PPO	$380.24

QuantF TB Gold Plus FSI

Facility

$392.00

Service Code	HCPCS 86480
Hospital Charge Code	8225274
Hospital Revenue Code	300
Min. Negotiated Rate	$51.95
Max. Negotiated Rate	$380.24
Rate for Payer: AlohaCare Medicaid	$196.00
Rate for Payer: AlohaCare Medicare	$196.00
Rate for Payer: Cash Price	$254.80
Rate for Payer: Cash Price	$254.80
Rate for Payer: Devoted Health Medicare	$215.60
Rate for Payer: Hawaii Medical Service Association ABD	$51.95
Rate for Payer: Hawaii Medical Service Association Commercial	$77.47
Rate for Payer: Hawaii Medical Service Association Medicare	$196.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$68.87
Rate for Payer: Hawaii Western Management Group Commercial	$61.98
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Humana Medicare	$196.00
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: Kaiser Permanente Medicaid	$199.92
Rate for Payer: Kaiser Permanente Medicare	$196.00
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: Ohana Health Plan Medicaid	$196.00
Rate for Payer: Ohana Health Plan Medicare	$196.00
Rate for Payer: UnitedHealthcare Medicaid	$51.95
Rate for Payer: UnitedHealthcare Medicare	$196.00
Rate for Payer: University Health Alliance Commercial	$160.19

QUEtiapine 100 mg tablet [HHSC]

Facility

$41.22

Service Code	NDC 60687034901
Hospital Charge Code	2500716
Hospital Revenue Code	250
Min. Negotiated Rate	$20.61
Max. Negotiated Rate	$39.98
Rate for Payer: AlohaCare Medicaid	$20.61
Rate for Payer: AlohaCare Medicare	$20.61
Rate for Payer: Cash Price	$26.79
Rate for Payer: Devoted Health Medicare	$22.67
Rate for Payer: Hawaii Medical Service Association Medicare	$20.61
Rate for Payer: Hawaii Western Management Group Commercial	$39.16
Rate for Payer: Health Management Network Commercial	$35.04
Rate for Payer: Humana Medicare	$20.61
Rate for Payer: Kaiser Permanente Commercial	$37.10
Rate for Payer: Kaiser Permanente Medicaid	$21.02
Rate for Payer: Kaiser Permanente Medicare	$20.61
Rate for Payer: MDX Hawaii PPO	$39.98
Rate for Payer: Ohana Health Plan Medicaid	$20.61
Rate for Payer: Ohana Health Plan Medicare	$20.61
Rate for Payer: UnitedHealthcare Medicaid	$24.73
Rate for Payer: UnitedHealthcare Medicare	$20.61
Rate for Payer: University Health Alliance Commercial	$30.05

QUEtiapine 100 mg tablet [HHSC]

Facility

$41.22

Service Code	NDC 60687034901
Hospital Charge Code	2500716
Hospital Revenue Code	250
Min. Negotiated Rate	$35.04
Max. Negotiated Rate	$39.98
Rate for Payer: Cash Price	$26.79
Rate for Payer: Health Management Network Commercial	$35.04
Rate for Payer: Kaiser Permanente Commercial	$37.10
Rate for Payer: MDX Hawaii PPO	$39.98

QUEtiapine 100 mg tablet [HHSC]

Facility

$41.22

Service Code	NDC 68084053201
Hospital Charge Code	2500716
Hospital Revenue Code	250
Min. Negotiated Rate	$35.04
Max. Negotiated Rate	$39.98
Rate for Payer: Cash Price	$26.79
Rate for Payer: Health Management Network Commercial	$35.04
Rate for Payer: Kaiser Permanente Commercial	$37.10
Rate for Payer: MDX Hawaii PPO	$39.98

QUEtiapine 100 mg tablet [HHSC]

Facility

$41.22

Service Code	NDC 68084053201
Hospital Charge Code	2500716
Hospital Revenue Code	250
Min. Negotiated Rate	$20.61
Max. Negotiated Rate	$39.98
Rate for Payer: AlohaCare Medicaid	$20.61
Rate for Payer: AlohaCare Medicare	$20.61
Rate for Payer: Cash Price	$26.79
Rate for Payer: Devoted Health Medicare	$22.67
Rate for Payer: Hawaii Medical Service Association Medicare	$20.61
Rate for Payer: Hawaii Western Management Group Commercial	$39.16
Rate for Payer: Health Management Network Commercial	$35.04
Rate for Payer: Humana Medicare	$20.61
Rate for Payer: Kaiser Permanente Commercial	$37.10
Rate for Payer: Kaiser Permanente Medicaid	$21.02
Rate for Payer: Kaiser Permanente Medicare	$20.61
Rate for Payer: MDX Hawaii PPO	$39.98
Rate for Payer: Ohana Health Plan Medicaid	$20.61
Rate for Payer: Ohana Health Plan Medicare	$20.61
Rate for Payer: UnitedHealthcare Medicaid	$24.73
Rate for Payer: UnitedHealthcare Medicare	$20.61
Rate for Payer: University Health Alliance Commercial	$30.05

QUEtiapine 200 mg tablet [HHSC]

Facility

$69.22

Service Code	NDC 60687036001
Hospital Charge Code	2500718
Hospital Revenue Code	250
Min. Negotiated Rate	$58.84
Max. Negotiated Rate	$67.14
Rate for Payer: Cash Price	$44.99
Rate for Payer: Health Management Network Commercial	$58.84
Rate for Payer: Kaiser Permanente Commercial	$62.30
Rate for Payer: MDX Hawaii PPO	$67.14

QUEtiapine 200 mg tablet [HHSC]

Facility

$6.34

Service Code	NDC 00904664161
Hospital Charge Code	2500718
Hospital Revenue Code	250
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$6.15
Rate for Payer: Cash Price	$4.12
Rate for Payer: Health Management Network Commercial	$5.39
Rate for Payer: Kaiser Permanente Commercial	$5.71
Rate for Payer: MDX Hawaii PPO	$6.15

QUEtiapine 200 mg tablet [HHSC]

Facility

$6.34

Service Code	NDC 00904664161
Hospital Charge Code	2500718
Hospital Revenue Code	250
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$6.15
Rate for Payer: AlohaCare Medicaid	$3.17
Rate for Payer: AlohaCare Medicare	$3.17
Rate for Payer: Cash Price	$4.12
Rate for Payer: Devoted Health Medicare	$3.49
Rate for Payer: Hawaii Medical Service Association Medicare	$3.17
Rate for Payer: Hawaii Western Management Group Commercial	$6.02
Rate for Payer: Health Management Network Commercial	$5.39
Rate for Payer: Humana Medicare	$3.17
Rate for Payer: Kaiser Permanente Commercial	$5.71
Rate for Payer: Kaiser Permanente Medicaid	$3.23
Rate for Payer: Kaiser Permanente Medicare	$3.17
Rate for Payer: MDX Hawaii PPO	$6.15
Rate for Payer: Ohana Health Plan Medicaid	$3.17
Rate for Payer: Ohana Health Plan Medicare	$3.17
Rate for Payer: UnitedHealthcare Medicaid	$3.80
Rate for Payer: UnitedHealthcare Medicare	$3.17
Rate for Payer: University Health Alliance Commercial	$4.62

QUEtiapine 200 mg tablet [HHSC]

Facility

$72.26

Service Code	NDC 67877024601
Hospital Charge Code	2500718
Hospital Revenue Code	250
Min. Negotiated Rate	$61.42
Max. Negotiated Rate	$70.09
Rate for Payer: Cash Price	$46.97
Rate for Payer: Health Management Network Commercial	$61.42
Rate for Payer: Kaiser Permanente Commercial	$65.03
Rate for Payer: MDX Hawaii PPO	$70.09

QUEtiapine 200 mg tablet [HHSC]

Facility

$72.26

Service Code	NDC 67877024601
Hospital Charge Code	2500718
Hospital Revenue Code	250
Min. Negotiated Rate	$36.13
Max. Negotiated Rate	$70.09
Rate for Payer: AlohaCare Medicaid	$36.13
Rate for Payer: AlohaCare Medicare	$36.13
Rate for Payer: Cash Price	$46.97
Rate for Payer: Devoted Health Medicare	$39.74
Rate for Payer: Hawaii Medical Service Association Medicare	$36.13
Rate for Payer: Hawaii Western Management Group Commercial	$68.65
Rate for Payer: Health Management Network Commercial	$61.42
Rate for Payer: Humana Medicare	$36.13
Rate for Payer: Kaiser Permanente Commercial	$65.03
Rate for Payer: Kaiser Permanente Medicaid	$36.85
Rate for Payer: Kaiser Permanente Medicare	$36.13
Rate for Payer: MDX Hawaii PPO	$70.09
Rate for Payer: Ohana Health Plan Medicaid	$36.13
Rate for Payer: Ohana Health Plan Medicare	$36.13
Rate for Payer: UnitedHealthcare Medicaid	$43.36
Rate for Payer: UnitedHealthcare Medicare	$36.13
Rate for Payer: University Health Alliance Commercial	$52.67

QUEtiapine 200 mg tablet [HHSC]

Facility

$69.22

Service Code	NDC 60687036001
Hospital Charge Code	2500718
Hospital Revenue Code	250
Min. Negotiated Rate	$34.61
Max. Negotiated Rate	$67.14
Rate for Payer: AlohaCare Medicaid	$34.61
Rate for Payer: AlohaCare Medicare	$34.61
Rate for Payer: Cash Price	$44.99
Rate for Payer: Devoted Health Medicare	$38.07
Rate for Payer: Hawaii Medical Service Association Medicare	$34.61
Rate for Payer: Hawaii Western Management Group Commercial	$65.76
Rate for Payer: Health Management Network Commercial	$58.84
Rate for Payer: Humana Medicare	$34.61
Rate for Payer: Kaiser Permanente Commercial	$62.30
Rate for Payer: Kaiser Permanente Medicaid	$35.30
Rate for Payer: Kaiser Permanente Medicare	$34.61
Rate for Payer: MDX Hawaii PPO	$67.14
Rate for Payer: Ohana Health Plan Medicaid	$34.61
Rate for Payer: Ohana Health Plan Medicare	$34.61
Rate for Payer: UnitedHealthcare Medicaid	$41.53
Rate for Payer: UnitedHealthcare Medicare	$34.61
Rate for Payer: University Health Alliance Commercial	$50.45

QUEtiapine 25 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904663861
Hospital Charge Code	2500719
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

QUEtiapine 25 mg tablet [HHSC]

Facility

$21.00

Service Code	NDC 60687032701
Hospital Charge Code	2500719
Hospital Revenue Code	250
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$20.37
Rate for Payer: AlohaCare Medicaid	$10.50
Rate for Payer: AlohaCare Medicare	$10.50
Rate for Payer: Cash Price	$13.65
Rate for Payer: Devoted Health Medicare	$11.55
Rate for Payer: Hawaii Medical Service Association Medicare	$10.50
Rate for Payer: Hawaii Western Management Group Commercial	$19.95
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Humana Medicare	$10.50
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: Kaiser Permanente Medicaid	$10.71
Rate for Payer: Kaiser Permanente Medicare	$10.50
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: Ohana Health Plan Medicaid	$10.50
Rate for Payer: Ohana Health Plan Medicare	$10.50
Rate for Payer: UnitedHealthcare Medicaid	$12.60
Rate for Payer: UnitedHealthcare Medicare	$10.50
Rate for Payer: University Health Alliance Commercial	$15.31

QUEtiapine 25 mg tablet [HHSC]

Facility

$21.00

Service Code	NDC 60687032701
Hospital Charge Code	2500719
Hospital Revenue Code	250
Min. Negotiated Rate	$17.85
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$13.65
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

QUEtiapine 25 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904663861
Hospital Charge Code	2500719
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

QUEtiapine 25 mg tablet [HHSC]

Facility

$22.24

Service Code	NDC 67877024201
Hospital Charge Code	2500719
Hospital Revenue Code	250
Min. Negotiated Rate	$11.12
Max. Negotiated Rate	$21.57
Rate for Payer: AlohaCare Medicaid	$11.12
Rate for Payer: AlohaCare Medicare	$11.12
Rate for Payer: Cash Price	$14.46
Rate for Payer: Devoted Health Medicare	$12.23
Rate for Payer: Hawaii Medical Service Association Medicare	$11.12
Rate for Payer: Hawaii Western Management Group Commercial	$21.13
Rate for Payer: Health Management Network Commercial	$18.90
Rate for Payer: Humana Medicare	$11.12
Rate for Payer: Kaiser Permanente Commercial	$20.02
Rate for Payer: Kaiser Permanente Medicaid	$11.34
Rate for Payer: Kaiser Permanente Medicare	$11.12
Rate for Payer: MDX Hawaii PPO	$21.57
Rate for Payer: Ohana Health Plan Medicaid	$11.12
Rate for Payer: Ohana Health Plan Medicare	$11.12
Rate for Payer: UnitedHealthcare Medicaid	$13.34
Rate for Payer: UnitedHealthcare Medicare	$11.12
Rate for Payer: University Health Alliance Commercial	$16.21

QUEtiapine 25 mg tablet [HHSC]

Facility

$22.24

Service Code	NDC 67877024201
Hospital Charge Code	2500719
Hospital Revenue Code	250
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$21.57
Rate for Payer: Cash Price	$14.46
Rate for Payer: Health Management Network Commercial	$18.90
Rate for Payer: Kaiser Permanente Commercial	$20.02
Rate for Payer: MDX Hawaii PPO	$21.57

QUEtiapine 300 mg tablet [HHSC]

Facility

$85.11

Service Code	NDC 60687037101
Hospital Charge Code	2500721
Hospital Revenue Code	250
Min. Negotiated Rate	$72.34
Max. Negotiated Rate	$82.56
Rate for Payer: Cash Price	$55.32
Rate for Payer: Health Management Network Commercial	$72.34
Rate for Payer: Kaiser Permanente Commercial	$76.60
Rate for Payer: MDX Hawaii PPO	$82.56

QUEtiapine 300 mg tablet [HHSC]

Facility

$85.11

Service Code	NDC 60687037101
Hospital Charge Code	2500721
Hospital Revenue Code	250
Min. Negotiated Rate	$42.55
Max. Negotiated Rate	$82.56
Rate for Payer: AlohaCare Medicaid	$42.55
Rate for Payer: AlohaCare Medicare	$42.55
Rate for Payer: Cash Price	$55.32
Rate for Payer: Devoted Health Medicare	$46.81
Rate for Payer: Hawaii Medical Service Association Medicare	$42.55
Rate for Payer: Hawaii Western Management Group Commercial	$80.85
Rate for Payer: Health Management Network Commercial	$72.34
Rate for Payer: Humana Medicare	$42.55
Rate for Payer: Kaiser Permanente Commercial	$76.60
Rate for Payer: Kaiser Permanente Medicaid	$43.41
Rate for Payer: Kaiser Permanente Medicare	$42.55
Rate for Payer: MDX Hawaii PPO	$82.56
Rate for Payer: Ohana Health Plan Medicaid	$42.55
Rate for Payer: Ohana Health Plan Medicare	$42.55
Rate for Payer: UnitedHealthcare Medicaid	$51.07
Rate for Payer: UnitedHealthcare Medicare	$42.55
Rate for Payer: University Health Alliance Commercial	$62.04

QUEtiapine 300 mg tablet [HHSC]

Facility

$89.05

Service Code	NDC 68001018306
Hospital Charge Code	2500721
Hospital Revenue Code	250
Min. Negotiated Rate	$75.69
Max. Negotiated Rate	$86.38
Rate for Payer: Cash Price	$57.88
Rate for Payer: Health Management Network Commercial	$75.69
Rate for Payer: Kaiser Permanente Commercial	$80.14
Rate for Payer: MDX Hawaii PPO	$86.38

QUEtiapine 300 mg tablet [HHSC]

Facility

$89.05

Service Code	NDC 68001018306
Hospital Charge Code	2500721
Hospital Revenue Code	250
Min. Negotiated Rate	$44.52
Max. Negotiated Rate	$86.38
Rate for Payer: AlohaCare Medicaid	$44.52
Rate for Payer: AlohaCare Medicare	$44.52
Rate for Payer: Cash Price	$57.88
Rate for Payer: Devoted Health Medicare	$48.98
Rate for Payer: Hawaii Medical Service Association Medicare	$44.52
Rate for Payer: Hawaii Western Management Group Commercial	$84.60
Rate for Payer: Health Management Network Commercial	$75.69
Rate for Payer: Humana Medicare	$44.52
Rate for Payer: Kaiser Permanente Commercial	$80.14
Rate for Payer: Kaiser Permanente Medicaid	$45.42
Rate for Payer: Kaiser Permanente Medicare	$44.52
Rate for Payer: MDX Hawaii PPO	$86.38
Rate for Payer: Ohana Health Plan Medicaid	$44.52
Rate for Payer: Ohana Health Plan Medicare	$44.52
Rate for Payer: UnitedHealthcare Medicaid	$53.43
Rate for Payer: UnitedHealthcare Medicare	$44.52
Rate for Payer: University Health Alliance Commercial	$64.91

QUEtiapine 300 mg tablet [HHSC]

Facility

$59.10

Service Code	NDC 50268063415
Hospital Charge Code	2500721
Hospital Revenue Code	250
Min. Negotiated Rate	$50.23
Max. Negotiated Rate	$57.33
Rate for Payer: Cash Price	$38.42
Rate for Payer: Health Management Network Commercial	$50.23
Rate for Payer: Kaiser Permanente Commercial	$53.19
Rate for Payer: MDX Hawaii PPO	$57.33

QUEtiapine 300 mg tablet [HHSC]

Facility

$89.47

Service Code	NDC 67877024760
Hospital Charge Code	2500721
Hospital Revenue Code	250
Min. Negotiated Rate	$76.05
Max. Negotiated Rate	$86.79
Rate for Payer: Cash Price	$58.16
Rate for Payer: Health Management Network Commercial	$76.05
Rate for Payer: Kaiser Permanente Commercial	$80.52
Rate for Payer: MDX Hawaii PPO	$86.79

Know your out-of-pocket cost for care.

All Charges