Kau Hospital

All Charges

Charge

Type

Setting

Price

OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]

Facility

$2.00

Service Code	NDC 60687067001
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]

Facility

$3.00

Service Code	NDC 10702020101
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]

Facility

$2.00

Service Code	NDC 60687067001
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]

Facility

$2.00

Service Code	NDC 60687067011
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]

Facility

$2.00

Service Code	NDC 60687067011
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$26.00

Service Code	NDC 66689040150
Hospital Revenue Code	637
Min. Negotiated Rate	$8.06
Max. Negotiated Rate	$25.22
Rate for Payer: AlohaCare Medicaid	$13.00
Rate for Payer: AlohaCare Medicare	$8.06
Rate for Payer: Cash Price	$15.60
Rate for Payer: Devoted Health Medicare	$8.84
Rate for Payer: Hawaii Medical Service Association Medicare	$8.06
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Humana Medicare	$8.06
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: Kaiser Permanente Medicare	$8.06
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: Ohana Health Plan Medicaid	$8.06
Rate for Payer: Ohana Health Plan Medicare	$8.06
Rate for Payer: UnitedHealthcare Medicare	$8.06
Rate for Payer: University Health Alliance Commercial	$18.95

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$26.00

Service Code	NDC 60687040640
Hospital Revenue Code	637
Min. Negotiated Rate	$8.06
Max. Negotiated Rate	$25.22
Rate for Payer: AlohaCare Medicaid	$13.00
Rate for Payer: AlohaCare Medicare	$8.06
Rate for Payer: Cash Price	$15.60
Rate for Payer: Devoted Health Medicare	$8.84
Rate for Payer: Hawaii Medical Service Association Medicare	$8.06
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Humana Medicare	$8.06
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: Kaiser Permanente Medicare	$8.06
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: Ohana Health Plan Medicaid	$8.06
Rate for Payer: Ohana Health Plan Medicare	$8.06
Rate for Payer: UnitedHealthcare Medicare	$8.06
Rate for Payer: University Health Alliance Commercial	$18.95

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$22.00

Service Code	NDC 64950035405
Hospital Revenue Code	637
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$21.34
Rate for Payer: AlohaCare Medicaid	$11.00
Rate for Payer: AlohaCare Medicare	$6.82
Rate for Payer: Cash Price	$13.20
Rate for Payer: Devoted Health Medicare	$7.48
Rate for Payer: Hawaii Medical Service Association Medicare	$6.82
Rate for Payer: Hawaii Western Management Group Commercial	$20.90
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Humana Medicare	$6.82
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: Kaiser Permanente Medicaid	$11.22
Rate for Payer: Kaiser Permanente Medicare	$6.82
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: Ohana Health Plan Medicaid	$6.82
Rate for Payer: Ohana Health Plan Medicare	$6.82
Rate for Payer: UnitedHealthcare Medicare	$6.82
Rate for Payer: University Health Alliance Commercial	$16.04

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$22.00

Service Code	NDC 64950035405
Hospital Revenue Code	250
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

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$22.00

Service Code	NDC 60687040677
Hospital Revenue Code	637
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$21.34
Rate for Payer: AlohaCare Medicaid	$11.00
Rate for Payer: AlohaCare Medicare	$6.82
Rate for Payer: Cash Price	$13.20
Rate for Payer: Devoted Health Medicare	$7.48
Rate for Payer: Hawaii Medical Service Association Medicare	$6.82
Rate for Payer: Hawaii Western Management Group Commercial	$20.90
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Humana Medicare	$6.82
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: Kaiser Permanente Medicaid	$11.22
Rate for Payer: Kaiser Permanente Medicare	$6.82
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: Ohana Health Plan Medicaid	$6.82
Rate for Payer: Ohana Health Plan Medicare	$6.82
Rate for Payer: UnitedHealthcare Medicare	$6.82
Rate for Payer: University Health Alliance Commercial	$16.04

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$26.00

Service Code	NDC 66689040150
Hospital Revenue Code	250
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: MDX Hawaii PPO	$25.22

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$22.00

Service Code	NDC 60687040677
Hospital Revenue Code	250
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

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$26.00

Service Code	NDC 60687040640
Hospital Revenue Code	250
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: MDX Hawaii PPO	$25.22

OXYCODONE 5 MG TABLET [10814]

Facility

$3.00

Service Code	NDC 00406055223
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

OXYCODONE 5 MG TABLET [10814]

Facility

$3.00

Service Code	NDC 00406055262
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

OXYCODONE 5 MG TABLET [10814]

Facility

$3.00

Service Code	NDC 00406055262
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
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

OXYCODONE 5 MG TABLET [10814]

Facility

$3.00

Service Code	NDC 00406055223
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
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

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	$4.65
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$4.65
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$5.10
Rate for Payer: Hawaii Medical Service Association Medicare	$4.65
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$4.65
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$4.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$4.65
Rate for Payer: Ohana Health Plan Medicare	$4.65
Rate for Payer: UnitedHealthcare Medicare	$4.65
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	$4.65
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$4.65
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$5.10
Rate for Payer: Hawaii Medical Service Association Medicare	$4.65
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$4.65
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$4.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$4.65
Rate for Payer: Ohana Health Plan Medicare	$4.65
Rate for Payer: UnitedHealthcare Medicare	$4.65
Rate for Payer: University Health Alliance Commercial	$10.93

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

Facility

$5.00

Service Code	NDC 60687064201
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

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

Facility

$7.00

Service Code	NDC 00406051262
Hospital Revenue Code	637
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$2.17
Rate for Payer: Cash Price	$4.20
Rate for Payer: Devoted Health Medicare	$2.38
Rate for Payer: Hawaii Medical Service Association Medicare	$2.17
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$2.17
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$2.17
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$2.17
Rate for Payer: Ohana Health Plan Medicare	$2.17
Rate for Payer: UnitedHealthcare Medicare	$2.17
Rate for Payer: University Health Alliance Commercial	$5.10

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

Facility

$7.00

Service Code	NDC 00406051223
Hospital Revenue Code	637
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$2.17
Rate for Payer: Cash Price	$4.20
Rate for Payer: Devoted Health Medicare	$2.38
Rate for Payer: Hawaii Medical Service Association Medicare	$2.17
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$2.17
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$2.17
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$2.17
Rate for Payer: Ohana Health Plan Medicare	$2.17
Rate for Payer: UnitedHealthcare Medicare	$2.17
Rate for Payer: University Health Alliance Commercial	$5.10

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

Know your out-of-pocket cost for care.

All Charges