Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

oxybutynin 5 mg tablet [HHSC]

Facility

$4.23

Service Code	NDC 10702020101
Hospital Charge Code	2500621
Hospital Revenue Code	250
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$4.10
Rate for Payer: Cash Price	$2.75
Rate for Payer: Health Management Network Commercial	$3.60
Rate for Payer: Kaiser Permanente Commercial	$3.81
Rate for Payer: MDX Hawaii PPO	$4.10

oxyCODONE 15 mg tablet [HHSC]

Facility

$10.40

Service Code	NDC 68084097501
Hospital Charge Code	2500623
Hospital Revenue Code	250
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$10.09
Rate for Payer: AlohaCare Medicaid	$5.20
Rate for Payer: AlohaCare Medicare	$5.20
Rate for Payer: Cash Price	$6.76
Rate for Payer: Devoted Health Medicare	$5.72
Rate for Payer: Hawaii Medical Service Association Medicare	$5.20
Rate for Payer: Hawaii Western Management Group Commercial	$9.88
Rate for Payer: Health Management Network Commercial	$8.84
Rate for Payer: Humana Medicare	$5.20
Rate for Payer: Kaiser Permanente Commercial	$9.36
Rate for Payer: Kaiser Permanente Medicaid	$5.30
Rate for Payer: Kaiser Permanente Medicare	$5.20
Rate for Payer: MDX Hawaii PPO	$10.09
Rate for Payer: Ohana Health Plan Medicaid	$5.20
Rate for Payer: Ohana Health Plan Medicare	$5.20
Rate for Payer: UnitedHealthcare Medicaid	$6.24
Rate for Payer: UnitedHealthcare Medicare	$5.20
Rate for Payer: University Health Alliance Commercial	$7.58

oxyCODONE 15 mg tablet [HHSC]

Facility

$10.54

Service Code	NDC 00406851501
Hospital Charge Code	2500623
Hospital Revenue Code	250
Min. Negotiated Rate	$8.96
Max. Negotiated Rate	$10.22
Rate for Payer: Cash Price	$6.85
Rate for Payer: Health Management Network Commercial	$8.96
Rate for Payer: Kaiser Permanente Commercial	$9.49
Rate for Payer: MDX Hawaii PPO	$10.22

oxyCODONE 15 mg tablet [HHSC]

Facility

$10.54

Service Code	NDC 00406851501
Hospital Charge Code	2500623
Hospital Revenue Code	250
Min. Negotiated Rate	$5.27
Max. Negotiated Rate	$10.22
Rate for Payer: AlohaCare Medicaid	$5.27
Rate for Payer: AlohaCare Medicare	$5.27
Rate for Payer: Cash Price	$6.85
Rate for Payer: Devoted Health Medicare	$5.80
Rate for Payer: Hawaii Medical Service Association Medicare	$5.27
Rate for Payer: Hawaii Western Management Group Commercial	$10.01
Rate for Payer: Health Management Network Commercial	$8.96
Rate for Payer: Humana Medicare	$5.27
Rate for Payer: Kaiser Permanente Commercial	$9.49
Rate for Payer: Kaiser Permanente Medicaid	$5.38
Rate for Payer: Kaiser Permanente Medicare	$5.27
Rate for Payer: MDX Hawaii PPO	$10.22
Rate for Payer: Ohana Health Plan Medicaid	$5.27
Rate for Payer: Ohana Health Plan Medicare	$5.27
Rate for Payer: UnitedHealthcare Medicaid	$6.32
Rate for Payer: UnitedHealthcare Medicare	$5.27
Rate for Payer: University Health Alliance Commercial	$7.68

oxyCODONE 15 mg tablet [HHSC]

Facility

$10.40

Service Code	NDC 68084018401
Hospital Charge Code	2500623
Hospital Revenue Code	250
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$10.09
Rate for Payer: Cash Price	$6.76
Rate for Payer: Health Management Network Commercial	$8.84
Rate for Payer: Kaiser Permanente Commercial	$9.36
Rate for Payer: MDX Hawaii PPO	$10.09

oxyCODONE 15 mg tablet [HHSC]

Facility

$10.54

Service Code	NDC 31722091701
Hospital Charge Code	2500623
Hospital Revenue Code	250
Min. Negotiated Rate	$5.27
Max. Negotiated Rate	$10.22
Rate for Payer: AlohaCare Medicaid	$5.27
Rate for Payer: AlohaCare Medicare	$5.27
Rate for Payer: Cash Price	$6.85
Rate for Payer: Devoted Health Medicare	$5.80
Rate for Payer: Hawaii Medical Service Association Medicare	$5.27
Rate for Payer: Hawaii Western Management Group Commercial	$10.01
Rate for Payer: Health Management Network Commercial	$8.96
Rate for Payer: Humana Medicare	$5.27
Rate for Payer: Kaiser Permanente Commercial	$9.49
Rate for Payer: Kaiser Permanente Medicaid	$5.38
Rate for Payer: Kaiser Permanente Medicare	$5.27
Rate for Payer: MDX Hawaii PPO	$10.22
Rate for Payer: Ohana Health Plan Medicaid	$5.27
Rate for Payer: Ohana Health Plan Medicare	$5.27
Rate for Payer: UnitedHealthcare Medicaid	$6.32
Rate for Payer: UnitedHealthcare Medicare	$5.27
Rate for Payer: University Health Alliance Commercial	$7.68

oxyCODONE 15 mg tablet [HHSC]

Facility

$10.40

Service Code	NDC 68084097501
Hospital Charge Code	2500623
Hospital Revenue Code	250
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$10.09
Rate for Payer: Cash Price	$6.76
Rate for Payer: Health Management Network Commercial	$8.84
Rate for Payer: Kaiser Permanente Commercial	$9.36
Rate for Payer: MDX Hawaii PPO	$10.09

oxyCODONE 15 mg tablet [HHSC]

Facility

$10.40

Service Code	NDC 68084018401
Hospital Charge Code	2500623
Hospital Revenue Code	250
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$10.09
Rate for Payer: AlohaCare Medicaid	$5.20
Rate for Payer: AlohaCare Medicare	$5.20
Rate for Payer: Cash Price	$6.76
Rate for Payer: Devoted Health Medicare	$5.72
Rate for Payer: Hawaii Medical Service Association Medicare	$5.20
Rate for Payer: Hawaii Western Management Group Commercial	$9.88
Rate for Payer: Health Management Network Commercial	$8.84
Rate for Payer: Humana Medicare	$5.20
Rate for Payer: Kaiser Permanente Commercial	$9.36
Rate for Payer: Kaiser Permanente Medicaid	$5.30
Rate for Payer: Kaiser Permanente Medicare	$5.20
Rate for Payer: MDX Hawaii PPO	$10.09
Rate for Payer: Ohana Health Plan Medicaid	$5.20
Rate for Payer: Ohana Health Plan Medicare	$5.20
Rate for Payer: UnitedHealthcare Medicaid	$6.24
Rate for Payer: UnitedHealthcare Medicare	$5.20
Rate for Payer: University Health Alliance Commercial	$7.58

oxyCODONE 15 mg tablet [HHSC]

Facility

$10.54

Service Code	NDC 31722091701
Hospital Charge Code	2500623
Hospital Revenue Code	250
Min. Negotiated Rate	$8.96
Max. Negotiated Rate	$10.22
Rate for Payer: Cash Price	$6.85
Rate for Payer: Health Management Network Commercial	$8.96
Rate for Payer: Kaiser Permanente Commercial	$9.49
Rate for Payer: MDX Hawaii PPO	$10.22

oxyCODONE 5 mg tablet [HHSC]

Facility

$3.45

Service Code	NDC 42858000110
Hospital Charge Code	2500625
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$3.35
Rate for Payer: AlohaCare Medicaid	$1.73
Rate for Payer: AlohaCare Medicare	$1.73
Rate for Payer: Cash Price	$2.24
Rate for Payer: Devoted Health Medicare	$1.90
Rate for Payer: Hawaii Medical Service Association Medicare	$1.73
Rate for Payer: Hawaii Western Management Group Commercial	$3.28
Rate for Payer: Health Management Network Commercial	$2.93
Rate for Payer: Humana Medicare	$1.73
Rate for Payer: Kaiser Permanente Commercial	$3.10
Rate for Payer: Kaiser Permanente Medicaid	$1.76
Rate for Payer: Kaiser Permanente Medicare	$1.73
Rate for Payer: MDX Hawaii PPO	$3.35
Rate for Payer: Ohana Health Plan Medicaid	$1.73
Rate for Payer: Ohana Health Plan Medicare	$1.73
Rate for Payer: UnitedHealthcare Medicaid	$2.07
Rate for Payer: UnitedHealthcare Medicare	$1.73
Rate for Payer: University Health Alliance Commercial	$2.51

oxyCODONE 5 mg tablet [HHSC]

Facility

$3.45

Service Code	NDC 42858000110
Hospital Charge Code	2500625
Hospital Revenue Code	250
Min. Negotiated Rate	$2.93
Max. Negotiated Rate	$3.35
Rate for Payer: Cash Price	$2.24
Rate for Payer: Health Management Network Commercial	$2.93
Rate for Payer: Kaiser Permanente Commercial	$3.10
Rate for Payer: MDX Hawaii PPO	$3.35

oxyCODONE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 68084035401
Hospital Charge Code	2500625
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

oxyCODONE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904696661
Hospital Charge Code	2500625
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

oxyCODONE 5 mg tablet [HHSC]

Facility

$3.01

Service Code	NDC 00406055262
Hospital Charge Code	2500625
Hospital Revenue Code	250
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$2.92
Rate for Payer: Cash Price	$1.96
Rate for Payer: Health Management Network Commercial	$2.56
Rate for Payer: Kaiser Permanente Commercial	$2.71
Rate for Payer: MDX Hawaii PPO	$2.92

oxyCODONE 5 mg tablet [HHSC]

Facility

$3.01

Service Code	NDC 00406055262
Hospital Charge Code	2500625
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.92
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.96
Rate for Payer: Devoted Health Medicare	$1.66
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.86
Rate for Payer: Health Management Network Commercial	$2.56
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.71
Rate for Payer: Kaiser Permanente Medicaid	$1.54
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.92
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.81
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

oxyCODONE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 68084035401
Hospital Charge Code	2500625
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

oxyCODONE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904696661
Hospital Charge Code	2500625
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

oxyCODONE-APAP 5-325 mg tablet [HHSC]

Facility

$7.61

Service Code	NDC 42858010201
Hospital Charge Code	2500012
Hospital Revenue Code	250
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$7.38
Rate for Payer: Cash Price	$4.95
Rate for Payer: Health Management Network Commercial	$6.47
Rate for Payer: Kaiser Permanente Commercial	$6.85
Rate for Payer: MDX Hawaii PPO	$7.38

oxyCODONE-APAP 5-325 mg tablet [HHSC]

Facility

$7.61

Service Code	NDC 00406051262
Hospital Charge Code	2500012
Hospital Revenue Code	250
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$7.38
Rate for Payer: AlohaCare Medicaid	$3.81
Rate for Payer: AlohaCare Medicare	$3.81
Rate for Payer: Cash Price	$4.95
Rate for Payer: Devoted Health Medicare	$4.19
Rate for Payer: Hawaii Medical Service Association Medicare	$3.81
Rate for Payer: Hawaii Western Management Group Commercial	$7.23
Rate for Payer: Health Management Network Commercial	$6.47
Rate for Payer: Humana Medicare	$3.81
Rate for Payer: Kaiser Permanente Commercial	$6.85
Rate for Payer: Kaiser Permanente Medicaid	$3.88
Rate for Payer: Kaiser Permanente Medicare	$3.81
Rate for Payer: MDX Hawaii PPO	$7.38
Rate for Payer: Ohana Health Plan Medicaid	$3.81
Rate for Payer: Ohana Health Plan Medicare	$3.81
Rate for Payer: UnitedHealthcare Medicaid	$4.57
Rate for Payer: UnitedHealthcare Medicare	$3.81
Rate for Payer: University Health Alliance Commercial	$5.55

oxyCODONE-APAP 5-325 mg tablet [HHSC]

Facility

$7.70

Service Code	NDC 68084035501
Hospital Charge Code	2500012
Hospital Revenue Code	250
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$7.47
Rate for Payer: AlohaCare Medicaid	$3.85
Rate for Payer: AlohaCare Medicare	$3.85
Rate for Payer: Cash Price	$5.00
Rate for Payer: Devoted Health Medicare	$4.24
Rate for Payer: Hawaii Medical Service Association Medicare	$3.85
Rate for Payer: Hawaii Western Management Group Commercial	$7.32
Rate for Payer: Health Management Network Commercial	$6.54
Rate for Payer: Humana Medicare	$3.85
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: Kaiser Permanente Medicaid	$3.93
Rate for Payer: Kaiser Permanente Medicare	$3.85
Rate for Payer: MDX Hawaii PPO	$7.47
Rate for Payer: Ohana Health Plan Medicaid	$3.85
Rate for Payer: Ohana Health Plan Medicare	$3.85
Rate for Payer: UnitedHealthcare Medicaid	$4.62
Rate for Payer: UnitedHealthcare Medicare	$3.85
Rate for Payer: University Health Alliance Commercial	$5.61

oxyCODONE-APAP 5-325 mg tablet [HHSC]

Facility

$7.61

Service Code	NDC 00406051201
Hospital Charge Code	2500012
Hospital Revenue Code	250
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$7.38
Rate for Payer: AlohaCare Medicaid	$3.81
Rate for Payer: AlohaCare Medicare	$3.81
Rate for Payer: Cash Price	$4.95
Rate for Payer: Devoted Health Medicare	$4.19
Rate for Payer: Hawaii Medical Service Association Medicare	$3.81
Rate for Payer: Hawaii Western Management Group Commercial	$7.23
Rate for Payer: Health Management Network Commercial	$6.47
Rate for Payer: Humana Medicare	$3.81
Rate for Payer: Kaiser Permanente Commercial	$6.85
Rate for Payer: Kaiser Permanente Medicaid	$3.88
Rate for Payer: Kaiser Permanente Medicare	$3.81
Rate for Payer: MDX Hawaii PPO	$7.38
Rate for Payer: Ohana Health Plan Medicaid	$3.81
Rate for Payer: Ohana Health Plan Medicare	$3.81
Rate for Payer: UnitedHealthcare Medicaid	$4.57
Rate for Payer: UnitedHealthcare Medicare	$3.81
Rate for Payer: University Health Alliance Commercial	$5.55

oxyCODONE-APAP 5-325 mg tablet [HHSC]

Facility

$7.61

Service Code	NDC 42858010201
Hospital Charge Code	2500012
Hospital Revenue Code	250
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$7.38
Rate for Payer: AlohaCare Medicaid	$3.81
Rate for Payer: AlohaCare Medicare	$3.81
Rate for Payer: Cash Price	$4.95
Rate for Payer: Devoted Health Medicare	$4.19
Rate for Payer: Hawaii Medical Service Association Medicare	$3.81
Rate for Payer: Hawaii Western Management Group Commercial	$7.23
Rate for Payer: Health Management Network Commercial	$6.47
Rate for Payer: Humana Medicare	$3.81
Rate for Payer: Kaiser Permanente Commercial	$6.85
Rate for Payer: Kaiser Permanente Medicaid	$3.88
Rate for Payer: Kaiser Permanente Medicare	$3.81
Rate for Payer: MDX Hawaii PPO	$7.38
Rate for Payer: Ohana Health Plan Medicaid	$3.81
Rate for Payer: Ohana Health Plan Medicare	$3.81
Rate for Payer: UnitedHealthcare Medicaid	$4.57
Rate for Payer: UnitedHealthcare Medicare	$3.81
Rate for Payer: University Health Alliance Commercial	$5.55

oxyCODONE-APAP 5-325 mg tablet [HHSC]

Facility

$7.70

Service Code	NDC 60687064201
Hospital Charge Code	2500012
Hospital Revenue Code	250
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$7.47
Rate for Payer: Cash Price	$5.00
Rate for Payer: Health Management Network Commercial	$6.54
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: MDX Hawaii PPO	$7.47

oxyCODONE-APAP 5-325 mg tablet [HHSC]

Facility

$7.70

Service Code	NDC 60687064201
Hospital Charge Code	2500012
Hospital Revenue Code	250
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$7.47
Rate for Payer: AlohaCare Medicaid	$3.85
Rate for Payer: AlohaCare Medicare	$3.85
Rate for Payer: Cash Price	$5.00
Rate for Payer: Devoted Health Medicare	$4.24
Rate for Payer: Hawaii Medical Service Association Medicare	$3.85
Rate for Payer: Hawaii Western Management Group Commercial	$7.32
Rate for Payer: Health Management Network Commercial	$6.54
Rate for Payer: Humana Medicare	$3.85
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: Kaiser Permanente Medicaid	$3.93
Rate for Payer: Kaiser Permanente Medicare	$3.85
Rate for Payer: MDX Hawaii PPO	$7.47
Rate for Payer: Ohana Health Plan Medicaid	$3.85
Rate for Payer: Ohana Health Plan Medicare	$3.85
Rate for Payer: UnitedHealthcare Medicaid	$4.62
Rate for Payer: UnitedHealthcare Medicare	$3.85
Rate for Payer: University Health Alliance Commercial	$5.61

oxyCODONE-APAP 5-325 mg tablet [HHSC]

Facility

$7.70

Service Code	NDC 68084035501
Hospital Charge Code	2500012
Hospital Revenue Code	250
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$7.47
Rate for Payer: Cash Price	$5.00
Rate for Payer: Health Management Network Commercial	$6.54
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: MDX Hawaii PPO	$7.47

Know your out-of-pocket cost for care.

All Charges