Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

metolazone 5 mg tablet [HHSC]

Facility

$13.10

Service Code	NDC 00185005501
Hospital Charge Code	2500539
Hospital Revenue Code	250
Min. Negotiated Rate	$6.55
Max. Negotiated Rate	$12.71
Rate for Payer: AlohaCare Medicaid	$6.55
Rate for Payer: AlohaCare Medicare	$6.55
Rate for Payer: Cash Price	$8.52
Rate for Payer: Devoted Health Medicare	$7.21
Rate for Payer: Hawaii Medical Service Association Medicare	$6.55
Rate for Payer: Hawaii Western Management Group Commercial	$12.45
Rate for Payer: Health Management Network Commercial	$11.13
Rate for Payer: Humana Medicare	$6.55
Rate for Payer: Kaiser Permanente Commercial	$11.79
Rate for Payer: Kaiser Permanente Medicaid	$6.68
Rate for Payer: Kaiser Permanente Medicare	$6.55
Rate for Payer: MDX Hawaii PPO	$12.71
Rate for Payer: Ohana Health Plan Medicaid	$6.55
Rate for Payer: Ohana Health Plan Medicare	$6.55
Rate for Payer: UnitedHealthcare Medicaid	$7.86
Rate for Payer: UnitedHealthcare Medicare	$6.55
Rate for Payer: University Health Alliance Commercial	$9.55

metolazone 5 mg tablet [HHSC]

Facility

$16.29

Service Code	NDC 00378617301
Hospital Charge Code	2500539
Hospital Revenue Code	250
Min. Negotiated Rate	$13.85
Max. Negotiated Rate	$15.80
Rate for Payer: Cash Price	$10.59
Rate for Payer: Health Management Network Commercial	$13.85
Rate for Payer: Kaiser Permanente Commercial	$14.66
Rate for Payer: MDX Hawaii PPO	$15.80

metolazone 5 mg tablet [HHSC]

Facility

$14.60

Service Code	NDC 76385013701
Hospital Charge Code	2500539
Hospital Revenue Code	250
Min. Negotiated Rate	$7.30
Max. Negotiated Rate	$14.16
Rate for Payer: AlohaCare Medicaid	$7.30
Rate for Payer: AlohaCare Medicare	$7.30
Rate for Payer: Cash Price	$9.49
Rate for Payer: Devoted Health Medicare	$8.03
Rate for Payer: Hawaii Medical Service Association Medicare	$7.30
Rate for Payer: Hawaii Western Management Group Commercial	$13.87
Rate for Payer: Health Management Network Commercial	$12.41
Rate for Payer: Humana Medicare	$7.30
Rate for Payer: Kaiser Permanente Commercial	$13.14
Rate for Payer: Kaiser Permanente Medicaid	$7.45
Rate for Payer: Kaiser Permanente Medicare	$7.30
Rate for Payer: MDX Hawaii PPO	$14.16
Rate for Payer: Ohana Health Plan Medicaid	$7.30
Rate for Payer: Ohana Health Plan Medicare	$7.30
Rate for Payer: UnitedHealthcare Medicaid	$8.76
Rate for Payer: UnitedHealthcare Medicare	$7.30
Rate for Payer: University Health Alliance Commercial	$10.64

metolazone 5 mg tablet [HHSC]

Facility

$14.60

Service Code	NDC 76385013701
Hospital Charge Code	2500539
Hospital Revenue Code	250
Min. Negotiated Rate	$12.41
Max. Negotiated Rate	$14.16
Rate for Payer: Cash Price	$9.49
Rate for Payer: Health Management Network Commercial	$12.41
Rate for Payer: Kaiser Permanente Commercial	$13.14
Rate for Payer: MDX Hawaii PPO	$14.16

metolazone 5 mg tablet [HHSC]

Facility

$20.76

Service Code	NDC 51079002420
Hospital Charge Code	2500539
Hospital Revenue Code	250
Min. Negotiated Rate	$10.38
Max. Negotiated Rate	$20.14
Rate for Payer: AlohaCare Medicaid	$10.38
Rate for Payer: AlohaCare Medicare	$10.38
Rate for Payer: Cash Price	$13.49
Rate for Payer: Devoted Health Medicare	$11.42
Rate for Payer: Hawaii Medical Service Association Medicare	$10.38
Rate for Payer: Hawaii Western Management Group Commercial	$19.72
Rate for Payer: Health Management Network Commercial	$17.65
Rate for Payer: Humana Medicare	$10.38
Rate for Payer: Kaiser Permanente Commercial	$18.68
Rate for Payer: Kaiser Permanente Medicaid	$10.59
Rate for Payer: Kaiser Permanente Medicare	$10.38
Rate for Payer: MDX Hawaii PPO	$20.14
Rate for Payer: Ohana Health Plan Medicaid	$10.38
Rate for Payer: Ohana Health Plan Medicare	$10.38
Rate for Payer: UnitedHealthcare Medicaid	$12.46
Rate for Payer: UnitedHealthcare Medicare	$10.38
Rate for Payer: University Health Alliance Commercial	$15.13

metolazone 5 mg tablet [HHSC]

Facility

$16.29

Service Code	NDC 00378617301
Hospital Charge Code	2500539
Hospital Revenue Code	250
Min. Negotiated Rate	$8.14
Max. Negotiated Rate	$15.80
Rate for Payer: AlohaCare Medicaid	$8.14
Rate for Payer: AlohaCare Medicare	$8.14
Rate for Payer: Cash Price	$10.59
Rate for Payer: Devoted Health Medicare	$8.96
Rate for Payer: Hawaii Medical Service Association Medicare	$8.14
Rate for Payer: Hawaii Western Management Group Commercial	$15.48
Rate for Payer: Health Management Network Commercial	$13.85
Rate for Payer: Humana Medicare	$8.14
Rate for Payer: Kaiser Permanente Commercial	$14.66
Rate for Payer: Kaiser Permanente Medicaid	$8.31
Rate for Payer: Kaiser Permanente Medicare	$8.14
Rate for Payer: MDX Hawaii PPO	$15.80
Rate for Payer: Ohana Health Plan Medicaid	$8.14
Rate for Payer: Ohana Health Plan Medicare	$8.14
Rate for Payer: UnitedHealthcare Medicaid	$9.77
Rate for Payer: UnitedHealthcare Medicare	$8.14
Rate for Payer: University Health Alliance Commercial	$11.87

metolazone 5 mg tablet [HHSC]

Facility

$16.29

Service Code	NDC 50742035001
Hospital Charge Code	2500539
Hospital Revenue Code	250
Min. Negotiated Rate	$13.85
Max. Negotiated Rate	$15.80
Rate for Payer: Cash Price	$10.59
Rate for Payer: Health Management Network Commercial	$13.85
Rate for Payer: Kaiser Permanente Commercial	$14.66
Rate for Payer: MDX Hawaii PPO	$15.80

metolazone 5 mg tablet [HHSC]

Facility

$16.29

Service Code	NDC 50742035001
Hospital Charge Code	2500539
Hospital Revenue Code	250
Min. Negotiated Rate	$8.14
Max. Negotiated Rate	$15.80
Rate for Payer: AlohaCare Medicaid	$8.14
Rate for Payer: AlohaCare Medicare	$8.14
Rate for Payer: Cash Price	$10.59
Rate for Payer: Devoted Health Medicare	$8.96
Rate for Payer: Hawaii Medical Service Association Medicare	$8.14
Rate for Payer: Hawaii Western Management Group Commercial	$15.48
Rate for Payer: Health Management Network Commercial	$13.85
Rate for Payer: Humana Medicare	$8.14
Rate for Payer: Kaiser Permanente Commercial	$14.66
Rate for Payer: Kaiser Permanente Medicaid	$8.31
Rate for Payer: Kaiser Permanente Medicare	$8.14
Rate for Payer: MDX Hawaii PPO	$15.80
Rate for Payer: Ohana Health Plan Medicaid	$8.14
Rate for Payer: Ohana Health Plan Medicare	$8.14
Rate for Payer: UnitedHealthcare Medicaid	$9.77
Rate for Payer: UnitedHealthcare Medicare	$8.14
Rate for Payer: University Health Alliance Commercial	$11.87

metoprolol 5 mg/5 ml vial [HHSC]

Facility

$7.01

Service Code	NDC 00409177805
Hospital Charge Code	2500540
Hospital Revenue Code	250
Min. Negotiated Rate	$5.96
Max. Negotiated Rate	$6.80
Rate for Payer: Cash Price	$4.56
Rate for Payer: Health Management Network Commercial	$5.96
Rate for Payer: Kaiser Permanente Commercial	$6.31
Rate for Payer: MDX Hawaii PPO	$6.80

metoprolol 5 mg/5 ml vial [HHSC]

Facility

$7.01

Service Code	NDC 00409177805
Hospital Charge Code	2500540
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$6.80
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$3.50
Rate for Payer: Cash Price	$4.56
Rate for Payer: Devoted Health Medicare	$3.86
Rate for Payer: Hawaii Medical Service Association Medicare	$3.50
Rate for Payer: Hawaii Western Management Group Commercial	$6.66
Rate for Payer: Health Management Network Commercial	$5.96
Rate for Payer: Humana Medicare	$3.50
Rate for Payer: Kaiser Permanente Commercial	$6.31
Rate for Payer: Kaiser Permanente Medicaid	$3.58
Rate for Payer: Kaiser Permanente Medicare	$3.50
Rate for Payer: MDX Hawaii PPO	$6.80
Rate for Payer: Ohana Health Plan Medicaid	$3.50
Rate for Payer: Ohana Health Plan Medicare	$3.50
Rate for Payer: UnitedHealthcare Medicaid	$4.21
Rate for Payer: UnitedHealthcare Medicare	$3.50
Rate for Payer: University Health Alliance Commercial	$5.11

metoprolol 5 mg/5 ml vial [HHSC]

Facility

$10.84

Service Code	NDC 36000003310
Hospital Charge Code	2500540
Hospital Revenue Code	250
Min. Negotiated Rate	$5.42
Max. Negotiated Rate	$10.51
Rate for Payer: AlohaCare Medicaid	$5.42
Rate for Payer: AlohaCare Medicare	$5.42
Rate for Payer: Cash Price	$7.05
Rate for Payer: Devoted Health Medicare	$5.96
Rate for Payer: Hawaii Medical Service Association Medicare	$5.42
Rate for Payer: Hawaii Western Management Group Commercial	$10.30
Rate for Payer: Health Management Network Commercial	$9.21
Rate for Payer: Humana Medicare	$5.42
Rate for Payer: Kaiser Permanente Commercial	$9.76
Rate for Payer: Kaiser Permanente Medicaid	$5.53
Rate for Payer: Kaiser Permanente Medicare	$5.42
Rate for Payer: MDX Hawaii PPO	$10.51
Rate for Payer: Ohana Health Plan Medicaid	$5.42
Rate for Payer: Ohana Health Plan Medicare	$5.42
Rate for Payer: UnitedHealthcare Medicaid	$6.50
Rate for Payer: UnitedHealthcare Medicare	$5.42
Rate for Payer: University Health Alliance Commercial	$7.90

metoprolol 5 mg/5 ml vial [HHSC]

Facility

$10.84

Service Code	NDC 36000003310
Hospital Charge Code	2500540
Hospital Revenue Code	250
Min. Negotiated Rate	$9.21
Max. Negotiated Rate	$10.51
Rate for Payer: Cash Price	$7.05
Rate for Payer: Health Management Network Commercial	$9.21
Rate for Payer: Kaiser Permanente Commercial	$9.76
Rate for Payer: MDX Hawaii PPO	$10.51

metoprolol 5 mg/5 ml vial [HHSC]

Facility

$6.54

Service Code	NDC 47781058717
Hospital Charge Code	2500540
Hospital Revenue Code	250
Min. Negotiated Rate	$5.56
Max. Negotiated Rate	$6.34
Rate for Payer: Cash Price	$4.25
Rate for Payer: Health Management Network Commercial	$5.56
Rate for Payer: Kaiser Permanente Commercial	$5.89
Rate for Payer: MDX Hawaii PPO	$6.34

metoprolol 5 mg/5 ml vial [HHSC]

Facility

$6.54

Service Code	NDC 72611074010
Hospital Charge Code	2500540
Hospital Revenue Code	250
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$6.34
Rate for Payer: AlohaCare Medicaid	$3.27
Rate for Payer: AlohaCare Medicare	$3.27
Rate for Payer: Cash Price	$4.25
Rate for Payer: Devoted Health Medicare	$3.60
Rate for Payer: Hawaii Medical Service Association Medicare	$3.27
Rate for Payer: Hawaii Western Management Group Commercial	$6.21
Rate for Payer: Health Management Network Commercial	$5.56
Rate for Payer: Humana Medicare	$3.27
Rate for Payer: Kaiser Permanente Commercial	$5.89
Rate for Payer: Kaiser Permanente Medicaid	$3.34
Rate for Payer: Kaiser Permanente Medicare	$3.27
Rate for Payer: MDX Hawaii PPO	$6.34
Rate for Payer: Ohana Health Plan Medicaid	$3.27
Rate for Payer: Ohana Health Plan Medicare	$3.27
Rate for Payer: UnitedHealthcare Medicaid	$3.92
Rate for Payer: UnitedHealthcare Medicare	$3.27
Rate for Payer: University Health Alliance Commercial	$4.77

metoprolol 5 mg/5 ml vial [HHSC]

Facility

$6.54

Service Code	NDC 47781058717
Hospital Charge Code	2500540
Hospital Revenue Code	250
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$6.34
Rate for Payer: AlohaCare Medicaid	$3.27
Rate for Payer: AlohaCare Medicare	$3.27
Rate for Payer: Cash Price	$4.25
Rate for Payer: Devoted Health Medicare	$3.60
Rate for Payer: Hawaii Medical Service Association Medicare	$3.27
Rate for Payer: Hawaii Western Management Group Commercial	$6.21
Rate for Payer: Health Management Network Commercial	$5.56
Rate for Payer: Humana Medicare	$3.27
Rate for Payer: Kaiser Permanente Commercial	$5.89
Rate for Payer: Kaiser Permanente Medicaid	$3.34
Rate for Payer: Kaiser Permanente Medicare	$3.27
Rate for Payer: MDX Hawaii PPO	$6.34
Rate for Payer: Ohana Health Plan Medicaid	$3.27
Rate for Payer: Ohana Health Plan Medicare	$3.27
Rate for Payer: UnitedHealthcare Medicaid	$3.92
Rate for Payer: UnitedHealthcare Medicare	$3.27
Rate for Payer: University Health Alliance Commercial	$4.77

metoprolol 5 mg/5 ml vial [HHSC]

Facility

$19.02

Service Code	NDC 25021030305
Hospital Charge Code	2500540
Hospital Revenue Code	250
Min. Negotiated Rate	$9.51
Max. Negotiated Rate	$18.45
Rate for Payer: AlohaCare Medicaid	$9.51
Rate for Payer: AlohaCare Medicare	$9.51
Rate for Payer: Cash Price	$12.36
Rate for Payer: Devoted Health Medicare	$10.46
Rate for Payer: Hawaii Medical Service Association Medicare	$9.51
Rate for Payer: Hawaii Western Management Group Commercial	$18.07
Rate for Payer: Health Management Network Commercial	$16.17
Rate for Payer: Humana Medicare	$9.51
Rate for Payer: Kaiser Permanente Commercial	$17.12
Rate for Payer: Kaiser Permanente Medicaid	$9.70
Rate for Payer: Kaiser Permanente Medicare	$9.51
Rate for Payer: MDX Hawaii PPO	$18.45
Rate for Payer: Ohana Health Plan Medicaid	$9.51
Rate for Payer: Ohana Health Plan Medicare	$9.51
Rate for Payer: UnitedHealthcare Medicaid	$11.41
Rate for Payer: UnitedHealthcare Medicare	$9.51
Rate for Payer: University Health Alliance Commercial	$13.86

metoprolol 5 mg/5 ml vial [HHSC]

Facility

$12.01

Service Code	NDC 70860030005
Hospital Charge Code	2500540
Hospital Revenue Code	250
Min. Negotiated Rate	$10.21
Max. Negotiated Rate	$11.65
Rate for Payer: Cash Price	$7.81
Rate for Payer: Health Management Network Commercial	$10.21
Rate for Payer: Kaiser Permanente Commercial	$10.81
Rate for Payer: MDX Hawaii PPO	$11.65

metoprolol 5 mg/5 ml vial [HHSC]

Facility

$19.02

Service Code	NDC 25021030305
Hospital Charge Code	2500540
Hospital Revenue Code	250
Min. Negotiated Rate	$16.17
Max. Negotiated Rate	$18.45
Rate for Payer: Cash Price	$12.36
Rate for Payer: Health Management Network Commercial	$16.17
Rate for Payer: Kaiser Permanente Commercial	$17.12
Rate for Payer: MDX Hawaii PPO	$18.45

metoprolol 5 mg/5 ml vial [HHSC]

Facility

$7.11

Service Code	NDC 00409201610
Hospital Charge Code	2500540
Hospital Revenue Code	250
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$6.90
Rate for Payer: AlohaCare Medicaid	$3.56
Rate for Payer: AlohaCare Medicare	$3.56
Rate for Payer: Cash Price	$4.62
Rate for Payer: Devoted Health Medicare	$3.91
Rate for Payer: Hawaii Medical Service Association Medicare	$3.56
Rate for Payer: Hawaii Western Management Group Commercial	$6.75
Rate for Payer: Health Management Network Commercial	$6.04
Rate for Payer: Humana Medicare	$3.56
Rate for Payer: Kaiser Permanente Commercial	$6.40
Rate for Payer: Kaiser Permanente Medicaid	$3.63
Rate for Payer: Kaiser Permanente Medicare	$3.56
Rate for Payer: MDX Hawaii PPO	$6.90
Rate for Payer: Ohana Health Plan Medicaid	$3.56
Rate for Payer: Ohana Health Plan Medicare	$3.56
Rate for Payer: UnitedHealthcare Medicaid	$4.27
Rate for Payer: UnitedHealthcare Medicare	$3.56
Rate for Payer: University Health Alliance Commercial	$5.18

metoprolol 5 mg/5 ml vial [HHSC]

Facility

$12.01

Service Code	NDC 70860030005
Hospital Charge Code	2500540
Hospital Revenue Code	250
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.65
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$6.00
Rate for Payer: Cash Price	$7.81
Rate for Payer: Devoted Health Medicare	$6.61
Rate for Payer: Hawaii Medical Service Association Medicare	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$11.41
Rate for Payer: Health Management Network Commercial	$10.21
Rate for Payer: Humana Medicare	$6.00
Rate for Payer: Kaiser Permanente Commercial	$10.81
Rate for Payer: Kaiser Permanente Medicaid	$6.13
Rate for Payer: Kaiser Permanente Medicare	$6.00
Rate for Payer: MDX Hawaii PPO	$11.65
Rate for Payer: Ohana Health Plan Medicaid	$6.00
Rate for Payer: Ohana Health Plan Medicare	$6.00
Rate for Payer: UnitedHealthcare Medicaid	$7.21
Rate for Payer: UnitedHealthcare Medicare	$6.00
Rate for Payer: University Health Alliance Commercial	$8.75

metoprolol 5 mg/5 ml vial [HHSC]

Facility

$6.54

Service Code	NDC 72611074010
Hospital Charge Code	2500540
Hospital Revenue Code	250
Min. Negotiated Rate	$5.56
Max. Negotiated Rate	$6.34
Rate for Payer: Cash Price	$4.25
Rate for Payer: Health Management Network Commercial	$5.56
Rate for Payer: Kaiser Permanente Commercial	$5.89
Rate for Payer: MDX Hawaii PPO	$6.34

metoprolol 5 mg/5 ml vial [HHSC]

Facility

$7.11

Service Code	NDC 00409201610
Hospital Charge Code	2500540
Hospital Revenue Code	250
Min. Negotiated Rate	$6.04
Max. Negotiated Rate	$6.90
Rate for Payer: Cash Price	$4.62
Rate for Payer: Health Management Network Commercial	$6.04
Rate for Payer: Kaiser Permanente Commercial	$6.40
Rate for Payer: MDX Hawaii PPO	$6.90

metoprolol 5 mg/5 ml vial [HHSC]

Facility

$8.67

Service Code	NDC 72266012225
Hospital Charge Code	2500540
Hospital Revenue Code	250
Min. Negotiated Rate	$4.33
Max. Negotiated Rate	$8.41
Rate for Payer: AlohaCare Medicaid	$4.33
Rate for Payer: AlohaCare Medicare	$4.33
Rate for Payer: Cash Price	$5.64
Rate for Payer: Devoted Health Medicare	$4.77
Rate for Payer: Hawaii Medical Service Association Medicare	$4.33
Rate for Payer: Hawaii Western Management Group Commercial	$8.24
Rate for Payer: Health Management Network Commercial	$7.37
Rate for Payer: Humana Medicare	$4.33
Rate for Payer: Kaiser Permanente Commercial	$7.80
Rate for Payer: Kaiser Permanente Medicaid	$4.42
Rate for Payer: Kaiser Permanente Medicare	$4.33
Rate for Payer: MDX Hawaii PPO	$8.41
Rate for Payer: Ohana Health Plan Medicaid	$4.33
Rate for Payer: Ohana Health Plan Medicare	$4.33
Rate for Payer: UnitedHealthcare Medicaid	$5.20
Rate for Payer: UnitedHealthcare Medicare	$4.33
Rate for Payer: University Health Alliance Commercial	$6.32

metoprolol 5 mg/5 ml vial [HHSC]

Facility

$8.67

Service Code	NDC 72266012225
Hospital Charge Code	2500540
Hospital Revenue Code	250
Min. Negotiated Rate	$7.37
Max. Negotiated Rate	$8.41
Rate for Payer: Cash Price	$5.64
Rate for Payer: Health Management Network Commercial	$7.37
Rate for Payer: Kaiser Permanente Commercial	$7.80
Rate for Payer: MDX Hawaii PPO	$8.41

metoprolol succ ER 25 mg tablet [HHSC]

Facility

$6.20

Service Code	NDC 68084065901
Hospital Charge Code	2500541
Hospital Revenue Code	250
Min. Negotiated Rate	$3.10
Max. Negotiated Rate	$6.01
Rate for Payer: AlohaCare Medicaid	$3.10
Rate for Payer: AlohaCare Medicare	$3.10
Rate for Payer: Cash Price	$4.03
Rate for Payer: Devoted Health Medicare	$3.41
Rate for Payer: Hawaii Medical Service Association Medicare	$3.10
Rate for Payer: Hawaii Western Management Group Commercial	$5.89
Rate for Payer: Health Management Network Commercial	$5.27
Rate for Payer: Humana Medicare	$3.10
Rate for Payer: Kaiser Permanente Commercial	$5.58
Rate for Payer: Kaiser Permanente Medicaid	$3.16
Rate for Payer: Kaiser Permanente Medicare	$3.10
Rate for Payer: MDX Hawaii PPO	$6.01
Rate for Payer: Ohana Health Plan Medicaid	$3.10
Rate for Payer: Ohana Health Plan Medicare	$3.10
Rate for Payer: UnitedHealthcare Medicaid	$3.72
Rate for Payer: UnitedHealthcare Medicare	$3.10
Rate for Payer: University Health Alliance Commercial	$4.52

Know your out-of-pocket cost for care.

All Charges