Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

OXYCODONE 5 MG TABLET [10814]

Facility

$3.00

Service Code	NDC 00406055223
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$2.19

OXYCODONE 5 MG TABLET (TAKE HOME) [4080384]

Facility

$15.00

Service Code	NDC 00004080172
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

OXYCODONE 5 MG TABLET (TAKE HOME) [4080384]

Facility

$15.00

Service Code	NDC 00004080172
Hospital Revenue Code	253
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$11.40
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association Medicare	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$11.40
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$11.40
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$11.40
Rate for Payer: Ohana Health Plan Medicare	$11.40
Rate for Payer: UnitedHealthcare Medicare	$11.40
Rate for Payer: University Health Alliance Commercial	$10.93

OXYCODONE/ACETAMINOPHEN 5/325 MG TABLETS (PERCOCET) (TAKE HOME) [4080385]

Facility

$15.00

Service Code	NDC 00004080173
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

OXYCODONE/ACETAMINOPHEN 5/325 MG TABLETS (PERCOCET) (TAKE HOME) [4080385]

Facility

$15.00

Service Code	NDC 00004080173
Hospital Revenue Code	253
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$11.40
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association Medicare	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$11.40
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$11.40
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$11.40
Rate for Payer: Ohana Health Plan Medicare	$11.40
Rate for Payer: UnitedHealthcare Medicare	$11.40
Rate for Payer: University Health Alliance Commercial	$10.93

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]

Facility

$7.00

Service Code	NDC 00406051262
Hospital Revenue Code	637
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$5.32
Rate for Payer: Cash Price	$4.20
Rate for Payer: Devoted Health Medicare	$5.88
Rate for Payer: Hawaii Medical Service Association Medicare	$5.32
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$5.32
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$5.32
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$5.32
Rate for Payer: Ohana Health Plan Medicare	$5.32
Rate for Payer: UnitedHealthcare Medicare	$5.32
Rate for Payer: University Health Alliance Commercial	$5.10

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]

Facility

$7.00

Service Code	NDC 00406051262
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]

Facility

$7.00

Service Code	NDC 00406051223
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]

Facility

$5.00

Service Code	NDC 60687064201
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

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]

Facility

$5.00

Service Code	NDC 60687064201
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

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]

Facility

$7.00

Service Code	NDC 00406051223
Hospital Revenue Code	637
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$5.32
Rate for Payer: Cash Price	$4.20
Rate for Payer: Devoted Health Medicare	$5.88
Rate for Payer: Hawaii Medical Service Association Medicare	$5.32
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$5.32
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$5.32
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$5.32
Rate for Payer: Ohana Health Plan Medicare	$5.32
Rate for Payer: UnitedHealthcare Medicare	$5.32
Rate for Payer: University Health Alliance Commercial	$5.10

OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [122363]

Facility

$21.00

Service Code	NDC 59011041020
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

OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [122363]

Facility

$21.00

Service Code	NDC 59011041020
Hospital Revenue Code	637
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$20.37
Rate for Payer: AlohaCare Medicaid	$10.50
Rate for Payer: AlohaCare Medicare	$15.96
Rate for Payer: Cash Price	$12.60
Rate for Payer: Devoted Health Medicare	$17.64
Rate for Payer: Hawaii Medical Service Association Medicare	$15.96
Rate for Payer: Hawaii Western Management Group Commercial	$19.95
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Humana Medicare	$15.96
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: Kaiser Permanente Medicaid	$10.71
Rate for Payer: Kaiser Permanente Medicare	$15.96
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: Ohana Health Plan Medicaid	$15.96
Rate for Payer: Ohana Health Plan Medicare	$15.96
Rate for Payer: UnitedHealthcare Medicare	$15.96
Rate for Payer: University Health Alliance Commercial	$15.31

OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [122366]

Facility

$33.00

Service Code	NDC 59011042020
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

OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [122366]

Facility

$33.00

Service Code	NDC 59011042020
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

OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [122368]

Facility

$56.00

Service Code	NDC 59011044020
Hospital Revenue Code	637
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$54.32
Rate for Payer: AlohaCare Medicaid	$28.00
Rate for Payer: AlohaCare Medicare	$42.56
Rate for Payer: Cash Price	$33.60
Rate for Payer: Devoted Health Medicare	$47.04
Rate for Payer: Hawaii Medical Service Association Medicare	$42.56
Rate for Payer: Hawaii Western Management Group Commercial	$53.20
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Humana Medicare	$42.56
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: Kaiser Permanente Medicaid	$28.56
Rate for Payer: Kaiser Permanente Medicare	$42.56
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: Ohana Health Plan Medicaid	$42.56
Rate for Payer: Ohana Health Plan Medicare	$42.56
Rate for Payer: UnitedHealthcare Medicare	$42.56
Rate for Payer: University Health Alliance Commercial	$40.82

OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [122368]

Facility

$56.00

Service Code	NDC 59011044020
Hospital Revenue Code	250
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$33.60
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: MDX Hawaii PPO	$54.32

OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]

Facility

$1.00

Service Code	NDC 00904676130
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

OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]

Facility

$10.00

Service Code	NDC 00904742730
Hospital Revenue Code	637
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$7.60
Rate for Payer: Cash Price	$6.00
Rate for Payer: Devoted Health Medicare	$8.40
Rate for Payer: Hawaii Medical Service Association Medicare	$7.60
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$7.60
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$7.60
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$7.60
Rate for Payer: Ohana Health Plan Medicare	$7.60
Rate for Payer: UnitedHealthcare Medicare	$7.60
Rate for Payer: University Health Alliance Commercial	$7.29

OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]

Facility

$1.00

Service Code	NDC 00904676130
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

OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]

Facility

$24.00

Service Code	NDC 46122016510
Hospital Revenue Code	637
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$18.24
Rate for Payer: Cash Price	$14.40
Rate for Payer: Devoted Health Medicare	$20.16
Rate for Payer: Hawaii Medical Service Association Medicare	$18.24
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$18.24
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$18.24
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$18.24
Rate for Payer: Ohana Health Plan Medicare	$18.24
Rate for Payer: UnitedHealthcare Medicare	$18.24
Rate for Payer: University Health Alliance Commercial	$17.49

OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]

Facility

$23.00

Service Code	NDC 81127000000
Hospital Revenue Code	250
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31

OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]

Facility

$23.00

Service Code	NDC 81127000000
Hospital Revenue Code	637
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$22.31
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$17.48
Rate for Payer: Cash Price	$13.80
Rate for Payer: Devoted Health Medicare	$19.32
Rate for Payer: Hawaii Medical Service Association Medicare	$17.48
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$17.48
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$17.48
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$17.48
Rate for Payer: Ohana Health Plan Medicare	$17.48
Rate for Payer: UnitedHealthcare Medicare	$17.48
Rate for Payer: University Health Alliance Commercial	$16.76

OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]

Facility

$10.00

Service Code	NDC 00904742730
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

OXYMETAZOLINE 0.05 % NASAL SPRAY [5943]

Facility

$24.00

Service Code	NDC 46122016510
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

Know your out-of-pocket cost for care.

All Charges