Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

cyanocobalamin 1000 mcg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00536355601
Hospital Charge Code	2500210
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

cyanocobalamin 1000 mcg tablet [HHSC]

Facility

$3.00

Service Code	NDC 68094011561
Hospital Charge Code	2500210
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

cyanocobalamin 1000 mcg tablet [HHSC]

Facility

$3.00

Service Code	NDC 77333093810
Hospital Charge Code	2500210
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
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 Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

cyanocobalamin 1000 mcg tablet [HHSC]

Facility

$3.00

Service Code	NDC 10006073043
Hospital Charge Code	2500210
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
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 Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

cyanocobalamin 1000 mcg tablet [HHSC]

Facility

$3.00

Service Code	NDC 77333093810
Hospital Charge Code	2500210
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

cyanocobalamin 1000 mcg tablet [HHSC]

Facility

$3.00

Service Code	NDC 68094011561
Hospital Charge Code	2500210
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
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 Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

cyanocobalamin 1000 mcg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00536355601
Hospital Charge Code	2500210
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
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 Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

cyanocobalamin 1000 mcg tablet [HHSC]

Facility

$3.00

Service Code	NDC 10006073043
Hospital Charge Code	2500210
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

cyclobenzaprine 10 mg tablet [HHSC]

Facility

$5.39

Service Code	NDC 51079064420
Hospital Charge Code	2500212
Hospital Revenue Code	250
Min. Negotiated Rate	$2.69
Max. Negotiated Rate	$5.23
Rate for Payer: AlohaCare Medicaid	$2.69
Rate for Payer: AlohaCare Medicare	$2.69
Rate for Payer: Cash Price	$3.50
Rate for Payer: Devoted Health Medicare	$2.96
Rate for Payer: Hawaii Medical Service Association Medicare	$2.69
Rate for Payer: Hawaii Western Management Group Commercial	$5.12
Rate for Payer: Health Management Network Commercial	$4.58
Rate for Payer: Humana Medicare	$2.69
Rate for Payer: Kaiser Permanente Commercial	$4.85
Rate for Payer: Kaiser Permanente Medicaid	$2.75
Rate for Payer: Kaiser Permanente Medicare	$2.69
Rate for Payer: MDX Hawaii PPO	$5.23
Rate for Payer: Ohana Health Plan Medicaid	$2.69
Rate for Payer: Ohana Health Plan Medicare	$2.69
Rate for Payer: UnitedHealthcare Medicaid	$3.23
Rate for Payer: UnitedHealthcare Medicare	$2.69
Rate for Payer: University Health Alliance Commercial	$3.93

cyclobenzaprine 10 mg tablet [HHSC]

Facility

$6.44

Service Code	NDC 43547040010
Hospital Charge Code	2500212
Hospital Revenue Code	250
Min. Negotiated Rate	$5.47
Max. Negotiated Rate	$6.25
Rate for Payer: Cash Price	$4.19
Rate for Payer: Health Management Network Commercial	$5.47
Rate for Payer: Kaiser Permanente Commercial	$5.80
Rate for Payer: MDX Hawaii PPO	$6.25

cyclobenzaprine 10 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687055801
Hospital Charge Code	2500212
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
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 Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

cyclobenzaprine 10 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687055801
Hospital Charge Code	2500212
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

cyclobenzaprine 10 mg tablet [HHSC]

Facility

$6.44

Service Code	NDC 29300041501
Hospital Charge Code	2500212
Hospital Revenue Code	250
Min. Negotiated Rate	$3.22
Max. Negotiated Rate	$6.25
Rate for Payer: AlohaCare Medicaid	$3.22
Rate for Payer: AlohaCare Medicare	$3.22
Rate for Payer: Cash Price	$4.19
Rate for Payer: Devoted Health Medicare	$3.54
Rate for Payer: Hawaii Medical Service Association Medicare	$3.22
Rate for Payer: Hawaii Western Management Group Commercial	$6.12
Rate for Payer: Health Management Network Commercial	$5.47
Rate for Payer: Humana Medicare	$3.22
Rate for Payer: Kaiser Permanente Commercial	$5.80
Rate for Payer: Kaiser Permanente Medicaid	$3.28
Rate for Payer: Kaiser Permanente Medicare	$3.22
Rate for Payer: MDX Hawaii PPO	$6.25
Rate for Payer: Ohana Health Plan Medicaid	$3.22
Rate for Payer: Ohana Health Plan Medicare	$3.22
Rate for Payer: UnitedHealthcare Medicaid	$3.86
Rate for Payer: UnitedHealthcare Medicare	$3.22
Rate for Payer: University Health Alliance Commercial	$4.69

cyclobenzaprine 10 mg tablet [HHSC]

Facility

$6.44

Service Code	NDC 43547040010
Hospital Charge Code	2500212
Hospital Revenue Code	250
Min. Negotiated Rate	$3.22
Max. Negotiated Rate	$6.25
Rate for Payer: AlohaCare Medicaid	$3.22
Rate for Payer: AlohaCare Medicare	$3.22
Rate for Payer: Cash Price	$4.19
Rate for Payer: Devoted Health Medicare	$3.54
Rate for Payer: Hawaii Medical Service Association Medicare	$3.22
Rate for Payer: Hawaii Western Management Group Commercial	$6.12
Rate for Payer: Health Management Network Commercial	$5.47
Rate for Payer: Humana Medicare	$3.22
Rate for Payer: Kaiser Permanente Commercial	$5.80
Rate for Payer: Kaiser Permanente Medicaid	$3.28
Rate for Payer: Kaiser Permanente Medicare	$3.22
Rate for Payer: MDX Hawaii PPO	$6.25
Rate for Payer: Ohana Health Plan Medicaid	$3.22
Rate for Payer: Ohana Health Plan Medicare	$3.22
Rate for Payer: UnitedHealthcare Medicaid	$3.86
Rate for Payer: UnitedHealthcare Medicare	$3.22
Rate for Payer: University Health Alliance Commercial	$4.69

cyclobenzaprine 10 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 63739053110
Hospital Charge Code	2500212
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

cyclobenzaprine 10 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 63739053110
Hospital Charge Code	2500212
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
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 Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

cyclobenzaprine 10 mg tablet [HHSC]

Facility

$5.39

Service Code	NDC 51079064420
Hospital Charge Code	2500212
Hospital Revenue Code	250
Min. Negotiated Rate	$4.58
Max. Negotiated Rate	$5.23
Rate for Payer: Cash Price	$3.50
Rate for Payer: Health Management Network Commercial	$4.58
Rate for Payer: Kaiser Permanente Commercial	$4.85
Rate for Payer: MDX Hawaii PPO	$5.23

cyclobenzaprine 10 mg tablet [HHSC]

Facility

$6.44

Service Code	NDC 29300041501
Hospital Charge Code	2500212
Hospital Revenue Code	250
Min. Negotiated Rate	$5.47
Max. Negotiated Rate	$6.25
Rate for Payer: Cash Price	$4.19
Rate for Payer: Health Management Network Commercial	$5.47
Rate for Payer: Kaiser Permanente Commercial	$5.80
Rate for Payer: MDX Hawaii PPO	$6.25

cyclobenzaprine 10 mg tablet [HHSC]

Facility

$6.72

Service Code	NDC 00904780961
Hospital Charge Code	2500212
Hospital Revenue Code	250
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$6.52
Rate for Payer: AlohaCare Medicaid	$3.36
Rate for Payer: AlohaCare Medicare	$3.36
Rate for Payer: Cash Price	$4.37
Rate for Payer: Devoted Health Medicare	$3.70
Rate for Payer: Hawaii Medical Service Association Medicare	$3.36
Rate for Payer: Hawaii Western Management Group Commercial	$6.38
Rate for Payer: Health Management Network Commercial	$5.71
Rate for Payer: Humana Medicare	$3.36
Rate for Payer: Kaiser Permanente Commercial	$6.05
Rate for Payer: Kaiser Permanente Medicaid	$3.43
Rate for Payer: Kaiser Permanente Medicare	$3.36
Rate for Payer: MDX Hawaii PPO	$6.52
Rate for Payer: Ohana Health Plan Medicaid	$3.36
Rate for Payer: Ohana Health Plan Medicare	$3.36
Rate for Payer: UnitedHealthcare Medicaid	$4.03
Rate for Payer: UnitedHealthcare Medicare	$3.36
Rate for Payer: University Health Alliance Commercial	$4.90

cyclobenzaprine 10 mg tablet [HHSC]

Facility

$6.72

Service Code	NDC 00904780961
Hospital Charge Code	2500212
Hospital Revenue Code	250
Min. Negotiated Rate	$5.71
Max. Negotiated Rate	$6.52
Rate for Payer: Cash Price	$4.37
Rate for Payer: Health Management Network Commercial	$5.71
Rate for Payer: Kaiser Permanente Commercial	$6.05
Rate for Payer: MDX Hawaii PPO	$6.52

cyclopentolate 1% ophth drops 2ml [HHSC]

Facility

$86.41

Service Code	NDC 24208073501
Hospital Charge Code	2500213
Hospital Revenue Code	250
Min. Negotiated Rate	$43.20
Max. Negotiated Rate	$83.82
Rate for Payer: AlohaCare Medicaid	$43.20
Rate for Payer: AlohaCare Medicare	$43.20
Rate for Payer: Cash Price	$56.17
Rate for Payer: Devoted Health Medicare	$47.53
Rate for Payer: Hawaii Medical Service Association Medicare	$43.20
Rate for Payer: Hawaii Western Management Group Commercial	$82.09
Rate for Payer: Health Management Network Commercial	$73.45
Rate for Payer: Humana Medicare	$43.20
Rate for Payer: Kaiser Permanente Commercial	$77.77
Rate for Payer: Kaiser Permanente Medicaid	$44.07
Rate for Payer: Kaiser Permanente Medicare	$43.20
Rate for Payer: MDX Hawaii PPO	$83.82
Rate for Payer: Ohana Health Plan Medicaid	$43.20
Rate for Payer: Ohana Health Plan Medicare	$43.20
Rate for Payer: UnitedHealthcare Medicaid	$51.85
Rate for Payer: UnitedHealthcare Medicare	$43.20
Rate for Payer: University Health Alliance Commercial	$62.98

cyclopentolate 1% ophth drops 2ml [HHSC]

Facility

$88.37

Service Code	NDC 61314039601
Hospital Charge Code	2500213
Hospital Revenue Code	250
Min. Negotiated Rate	$75.11
Max. Negotiated Rate	$85.72
Rate for Payer: Cash Price	$57.44
Rate for Payer: Health Management Network Commercial	$75.11
Rate for Payer: Kaiser Permanente Commercial	$79.53
Rate for Payer: MDX Hawaii PPO	$85.72

cyclopentolate 1% ophth drops 2ml [HHSC]

Facility

$79.93

Service Code	NDC 17478010002
Hospital Charge Code	2500213
Hospital Revenue Code	250
Min. Negotiated Rate	$39.97
Max. Negotiated Rate	$77.53
Rate for Payer: AlohaCare Medicaid	$39.97
Rate for Payer: AlohaCare Medicare	$39.97
Rate for Payer: Cash Price	$51.95
Rate for Payer: Devoted Health Medicare	$43.96
Rate for Payer: Hawaii Medical Service Association Medicare	$39.97
Rate for Payer: Hawaii Western Management Group Commercial	$75.93
Rate for Payer: Health Management Network Commercial	$67.94
Rate for Payer: Humana Medicare	$39.97
Rate for Payer: Kaiser Permanente Commercial	$71.94
Rate for Payer: Kaiser Permanente Medicaid	$40.76
Rate for Payer: Kaiser Permanente Medicare	$39.97
Rate for Payer: MDX Hawaii PPO	$77.53
Rate for Payer: Ohana Health Plan Medicaid	$39.97
Rate for Payer: Ohana Health Plan Medicare	$39.97
Rate for Payer: UnitedHealthcare Medicaid	$47.96
Rate for Payer: UnitedHealthcare Medicare	$39.97
Rate for Payer: University Health Alliance Commercial	$58.26

cyclopentolate 1% ophth drops 2ml [HHSC]

Facility

$88.37

Service Code	NDC 61314039601
Hospital Charge Code	2500213
Hospital Revenue Code	250
Min. Negotiated Rate	$44.19
Max. Negotiated Rate	$85.72
Rate for Payer: AlohaCare Medicaid	$44.19
Rate for Payer: AlohaCare Medicare	$44.19
Rate for Payer: Cash Price	$57.44
Rate for Payer: Devoted Health Medicare	$48.60
Rate for Payer: Hawaii Medical Service Association Medicare	$44.19
Rate for Payer: Hawaii Western Management Group Commercial	$83.95
Rate for Payer: Health Management Network Commercial	$75.11
Rate for Payer: Humana Medicare	$44.19
Rate for Payer: Kaiser Permanente Commercial	$79.53
Rate for Payer: Kaiser Permanente Medicaid	$45.07
Rate for Payer: Kaiser Permanente Medicare	$44.19
Rate for Payer: MDX Hawaii PPO	$85.72
Rate for Payer: Ohana Health Plan Medicaid	$44.19
Rate for Payer: Ohana Health Plan Medicare	$44.19
Rate for Payer: UnitedHealthcare Medicaid	$53.02
Rate for Payer: UnitedHealthcare Medicare	$44.19
Rate for Payer: University Health Alliance Commercial	$64.41

cyclopentolate 1% ophth drops 2ml [HHSC]

Facility

$86.41

Service Code	NDC 24208073501
Hospital Charge Code	2500213
Hospital Revenue Code	250
Min. Negotiated Rate	$73.45
Max. Negotiated Rate	$83.82
Rate for Payer: Cash Price	$56.17
Rate for Payer: Health Management Network Commercial	$73.45
Rate for Payer: Kaiser Permanente Commercial	$77.77
Rate for Payer: MDX Hawaii PPO	$83.82

Know your out-of-pocket cost for care.

All Charges