Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

oxyCODONE-APAP 5-325 mg tablet [HHSC]

Facility

$7.60

Service Code	NDC 50268064415
Hospital Charge Code	2500012
Hospital Revenue Code	250
Min. Negotiated Rate	$3.80
Max. Negotiated Rate	$7.37
Rate for Payer: AlohaCare Medicaid	$3.80
Rate for Payer: AlohaCare Medicare	$3.80
Rate for Payer: Cash Price	$4.94
Rate for Payer: Devoted Health Medicare	$4.18
Rate for Payer: Hawaii Medical Service Association Medicare	$3.80
Rate for Payer: Hawaii Western Management Group Commercial	$7.22
Rate for Payer: Health Management Network Commercial	$6.46
Rate for Payer: Humana Medicare	$3.80
Rate for Payer: Kaiser Permanente Commercial	$6.84
Rate for Payer: Kaiser Permanente Medicaid	$3.88
Rate for Payer: Kaiser Permanente Medicare	$3.80
Rate for Payer: MDX Hawaii PPO	$7.37
Rate for Payer: Ohana Health Plan Medicaid	$3.80
Rate for Payer: Ohana Health Plan Medicare	$3.80
Rate for Payer: UnitedHealthcare Medicaid	$4.56
Rate for Payer: UnitedHealthcare Medicare	$3.80
Rate for Payer: University Health Alliance Commercial	$5.54

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	$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	$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

$7.60

Service Code	NDC 50268064415
Hospital Charge Code	2500012
Hospital Revenue Code	250
Min. Negotiated Rate	$6.46
Max. Negotiated Rate	$7.37
Rate for Payer: Cash Price	$4.94
Rate for Payer: Health Management Network Commercial	$6.46
Rate for Payer: Kaiser Permanente Commercial	$6.84
Rate for Payer: MDX Hawaii PPO	$7.37

oxyCODONE CR 10 mg tablet [HHSC]

Facility

$25.07

Service Code	NDC 59011041020
Hospital Charge Code	2500622
Hospital Revenue Code	250
Min. Negotiated Rate	$21.31
Max. Negotiated Rate	$24.32
Rate for Payer: Cash Price	$16.30
Rate for Payer: Health Management Network Commercial	$21.31
Rate for Payer: Kaiser Permanente Commercial	$22.56
Rate for Payer: MDX Hawaii PPO	$24.32

oxyCODONE CR 10 mg tablet [HHSC]

Facility

$42.79

Service Code	NDC 59011041010
Hospital Charge Code	2500622
Hospital Revenue Code	250
Min. Negotiated Rate	$36.37
Max. Negotiated Rate	$41.51
Rate for Payer: Cash Price	$27.81
Rate for Payer: Health Management Network Commercial	$36.37
Rate for Payer: Kaiser Permanente Commercial	$38.51
Rate for Payer: MDX Hawaii PPO	$41.51

oxyCODONE CR 10 mg tablet [HHSC]

Facility

$25.07

Service Code	NDC 59011041020
Hospital Charge Code	2500622
Hospital Revenue Code	250
Min. Negotiated Rate	$12.54
Max. Negotiated Rate	$24.32
Rate for Payer: AlohaCare Medicaid	$12.54
Rate for Payer: AlohaCare Medicare	$12.54
Rate for Payer: Cash Price	$16.30
Rate for Payer: Devoted Health Medicare	$13.79
Rate for Payer: Hawaii Medical Service Association Medicare	$12.54
Rate for Payer: Hawaii Western Management Group Commercial	$23.82
Rate for Payer: Health Management Network Commercial	$21.31
Rate for Payer: Humana Medicare	$12.54
Rate for Payer: Kaiser Permanente Commercial	$22.56
Rate for Payer: Kaiser Permanente Medicaid	$12.79
Rate for Payer: Kaiser Permanente Medicare	$12.54
Rate for Payer: MDX Hawaii PPO	$24.32
Rate for Payer: Ohana Health Plan Medicaid	$12.54
Rate for Payer: Ohana Health Plan Medicare	$12.54
Rate for Payer: UnitedHealthcare Medicaid	$15.04
Rate for Payer: UnitedHealthcare Medicare	$12.54
Rate for Payer: University Health Alliance Commercial	$18.27

oxyCODONE CR 10 mg tablet [HHSC]

Facility

$42.79

Service Code	NDC 59011041010
Hospital Charge Code	2500622
Hospital Revenue Code	250
Min. Negotiated Rate	$21.39
Max. Negotiated Rate	$41.51
Rate for Payer: AlohaCare Medicaid	$21.39
Rate for Payer: AlohaCare Medicare	$21.39
Rate for Payer: Cash Price	$27.81
Rate for Payer: Devoted Health Medicare	$23.53
Rate for Payer: Hawaii Medical Service Association Medicare	$21.39
Rate for Payer: Hawaii Western Management Group Commercial	$40.65
Rate for Payer: Health Management Network Commercial	$36.37
Rate for Payer: Humana Medicare	$21.39
Rate for Payer: Kaiser Permanente Commercial	$38.51
Rate for Payer: Kaiser Permanente Medicaid	$21.82
Rate for Payer: Kaiser Permanente Medicare	$21.39
Rate for Payer: MDX Hawaii PPO	$41.51
Rate for Payer: Ohana Health Plan Medicaid	$21.39
Rate for Payer: Ohana Health Plan Medicare	$21.39
Rate for Payer: UnitedHealthcare Medicaid	$25.67
Rate for Payer: UnitedHealthcare Medicare	$21.39
Rate for Payer: University Health Alliance Commercial	$31.19

oxyCODONE CR 40 mg tablet [HHSC]

Facility

$78.26

Service Code	NDC 59011044020
Hospital Charge Code	2500624
Hospital Revenue Code	250
Min. Negotiated Rate	$66.52
Max. Negotiated Rate	$75.91
Rate for Payer: Cash Price	$50.87
Rate for Payer: Health Management Network Commercial	$66.52
Rate for Payer: Kaiser Permanente Commercial	$70.43
Rate for Payer: MDX Hawaii PPO	$75.91

oxyCODONE CR 40 mg tablet [HHSC]

Facility

$78.26

Service Code	NDC 59011044020
Hospital Charge Code	2500624
Hospital Revenue Code	250
Min. Negotiated Rate	$39.13
Max. Negotiated Rate	$75.91
Rate for Payer: AlohaCare Medicaid	$39.13
Rate for Payer: AlohaCare Medicare	$39.13
Rate for Payer: Cash Price	$50.87
Rate for Payer: Devoted Health Medicare	$43.04
Rate for Payer: Hawaii Medical Service Association Medicare	$39.13
Rate for Payer: Hawaii Western Management Group Commercial	$74.35
Rate for Payer: Health Management Network Commercial	$66.52
Rate for Payer: Humana Medicare	$39.13
Rate for Payer: Kaiser Permanente Commercial	$70.43
Rate for Payer: Kaiser Permanente Medicaid	$39.91
Rate for Payer: Kaiser Permanente Medicare	$39.13
Rate for Payer: MDX Hawaii PPO	$75.91
Rate for Payer: Ohana Health Plan Medicaid	$39.13
Rate for Payer: Ohana Health Plan Medicare	$39.13
Rate for Payer: UnitedHealthcare Medicaid	$46.96
Rate for Payer: UnitedHealthcare Medicare	$39.13
Rate for Payer: University Health Alliance Commercial	$57.04

Oxygen Per Hour Charge

Facility

$18.00

Hospital Charge Code	8449974
Hospital Revenue Code	270
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$11.70
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: MDX Hawaii PPO	$17.46

Oxygen Per Hour Charge

Facility

$18.00

Hospital Charge Code	8449974
Hospital Revenue Code	270
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$17.46
Rate for Payer: AlohaCare Medicaid	$9.00
Rate for Payer: AlohaCare Medicare	$9.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Devoted Health Medicare	$9.90
Rate for Payer: Hawaii Medical Service Association Medicare	$9.00
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Humana Medicare	$9.00
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicare	$9.00
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: Ohana Health Plan Medicaid	$9.00
Rate for Payer: Ohana Health Plan Medicare	$9.00
Rate for Payer: UnitedHealthcare Medicare	$9.00
Rate for Payer: University Health Alliance Commercial	$13.12

OXYGEN THERAPY CHARGE DAILY

Facility

$360.00

Hospital Charge Code	8279005
Hospital Revenue Code	270
Min. Negotiated Rate	$306.00
Max. Negotiated Rate	$349.20
Rate for Payer: Cash Price	$234.00
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: Kaiser Permanente Commercial	$324.00
Rate for Payer: MDX Hawaii PPO	$349.20

OXYGEN THERAPY CHARGE DAILY

Facility

$360.00

Hospital Charge Code	8279005
Hospital Revenue Code	270
Min. Negotiated Rate	$180.00
Max. Negotiated Rate	$349.20
Rate for Payer: AlohaCare Medicaid	$180.00
Rate for Payer: AlohaCare Medicare	$180.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Devoted Health Medicare	$198.00
Rate for Payer: Hawaii Medical Service Association Medicare	$180.00
Rate for Payer: Hawaii Western Management Group Commercial	$342.00
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: Humana Medicare	$180.00
Rate for Payer: Kaiser Permanente Commercial	$324.00
Rate for Payer: Kaiser Permanente Medicaid	$183.60
Rate for Payer: Kaiser Permanente Medicare	$180.00
Rate for Payer: MDX Hawaii PPO	$349.20
Rate for Payer: Ohana Health Plan Medicaid	$180.00
Rate for Payer: Ohana Health Plan Medicare	$180.00
Rate for Payer: UnitedHealthcare Medicare	$180.00
Rate for Payer: University Health Alliance Commercial	$262.40

Oxygen Therapy High-Flow Nasal Cannula

Facility

$532.00

Hospital Charge Code	9277861
Hospital Revenue Code	272
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$516.04
Rate for Payer: AlohaCare Medicaid	$266.00
Rate for Payer: AlohaCare Medicare	$266.00
Rate for Payer: Cash Price	$345.80
Rate for Payer: Devoted Health Medicare	$292.60
Rate for Payer: Hawaii Medical Service Association Medicare	$266.00
Rate for Payer: Hawaii Western Management Group Commercial	$505.40
Rate for Payer: Health Management Network Commercial	$452.20
Rate for Payer: Humana Medicare	$266.00
Rate for Payer: Kaiser Permanente Commercial	$478.80
Rate for Payer: Kaiser Permanente Medicaid	$271.32
Rate for Payer: Kaiser Permanente Medicare	$266.00
Rate for Payer: MDX Hawaii PPO	$516.04
Rate for Payer: Ohana Health Plan Medicaid	$266.00
Rate for Payer: Ohana Health Plan Medicare	$266.00
Rate for Payer: UnitedHealthcare Medicare	$266.00
Rate for Payer: University Health Alliance Commercial	$387.77

Oxygen Therapy High-Flow Nasal Cannula

Facility

$532.00

Hospital Charge Code	9277861
Hospital Revenue Code	272
Min. Negotiated Rate	$452.20
Max. Negotiated Rate	$516.04
Rate for Payer: Cash Price	$345.80
Rate for Payer: Health Management Network Commercial	$452.20
Rate for Payer: Kaiser Permanente Commercial	$478.80
Rate for Payer: MDX Hawaii PPO	$516.04

Oxygen Therapy Low-Flow Nasal Cannula

Facility

$532.00

Hospital Charge Code	9277862
Hospital Revenue Code	272
Min. Negotiated Rate	$452.20
Max. Negotiated Rate	$516.04
Rate for Payer: Cash Price	$345.80
Rate for Payer: Health Management Network Commercial	$452.20
Rate for Payer: Kaiser Permanente Commercial	$478.80
Rate for Payer: MDX Hawaii PPO	$516.04

Oxygen Therapy Low-Flow Nasal Cannula

Facility

$532.00

Hospital Charge Code	9277862
Hospital Revenue Code	272
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$516.04
Rate for Payer: AlohaCare Medicaid	$266.00
Rate for Payer: AlohaCare Medicare	$266.00
Rate for Payer: Cash Price	$345.80
Rate for Payer: Devoted Health Medicare	$292.60
Rate for Payer: Hawaii Medical Service Association Medicare	$266.00
Rate for Payer: Hawaii Western Management Group Commercial	$505.40
Rate for Payer: Health Management Network Commercial	$452.20
Rate for Payer: Humana Medicare	$266.00
Rate for Payer: Kaiser Permanente Commercial	$478.80
Rate for Payer: Kaiser Permanente Medicaid	$271.32
Rate for Payer: Kaiser Permanente Medicare	$266.00
Rate for Payer: MDX Hawaii PPO	$516.04
Rate for Payer: Ohana Health Plan Medicaid	$266.00
Rate for Payer: Ohana Health Plan Medicare	$266.00
Rate for Payer: UnitedHealthcare Medicare	$266.00
Rate for Payer: University Health Alliance Commercial	$387.77

oxymetazoline 0.05% 15ml spray nasal [HHSC]

Facility

$27.96

Service Code	NDC 11523116706
Hospital Charge Code	2500626
Hospital Revenue Code	250
Min. Negotiated Rate	$13.98
Max. Negotiated Rate	$27.12
Rate for Payer: AlohaCare Medicaid	$13.98
Rate for Payer: AlohaCare Medicare	$13.98
Rate for Payer: Cash Price	$18.17
Rate for Payer: Devoted Health Medicare	$15.38
Rate for Payer: Hawaii Medical Service Association Medicare	$13.98
Rate for Payer: Hawaii Western Management Group Commercial	$26.56
Rate for Payer: Health Management Network Commercial	$23.77
Rate for Payer: Humana Medicare	$13.98
Rate for Payer: Kaiser Permanente Commercial	$25.16
Rate for Payer: Kaiser Permanente Medicaid	$14.26
Rate for Payer: Kaiser Permanente Medicare	$13.98
Rate for Payer: MDX Hawaii PPO	$27.12
Rate for Payer: Ohana Health Plan Medicaid	$13.98
Rate for Payer: Ohana Health Plan Medicare	$13.98
Rate for Payer: UnitedHealthcare Medicaid	$16.78
Rate for Payer: UnitedHealthcare Medicare	$13.98
Rate for Payer: University Health Alliance Commercial	$20.38

oxymetazoline 0.05% 15ml spray nasal [HHSC]

Facility

$26.63

Service Code	NDC 11523411201
Hospital Charge Code	2500626
Hospital Revenue Code	250
Min. Negotiated Rate	$22.64
Max. Negotiated Rate	$25.83
Rate for Payer: Cash Price	$17.31
Rate for Payer: Health Management Network Commercial	$22.64
Rate for Payer: Kaiser Permanente Commercial	$23.97
Rate for Payer: MDX Hawaii PPO	$25.83

oxymetazoline 0.05% 15ml spray nasal [HHSC]

Facility

$26.63

Service Code	NDC 11523411201
Hospital Charge Code	2500626
Hospital Revenue Code	250
Min. Negotiated Rate	$13.31
Max. Negotiated Rate	$25.83
Rate for Payer: AlohaCare Medicaid	$13.31
Rate for Payer: AlohaCare Medicare	$13.31
Rate for Payer: Cash Price	$17.31
Rate for Payer: Devoted Health Medicare	$14.65
Rate for Payer: Hawaii Medical Service Association Medicare	$13.31
Rate for Payer: Hawaii Western Management Group Commercial	$25.30
Rate for Payer: Health Management Network Commercial	$22.64
Rate for Payer: Humana Medicare	$13.31
Rate for Payer: Kaiser Permanente Commercial	$23.97
Rate for Payer: Kaiser Permanente Medicaid	$13.58
Rate for Payer: Kaiser Permanente Medicare	$13.31
Rate for Payer: MDX Hawaii PPO	$25.83
Rate for Payer: Ohana Health Plan Medicaid	$13.31
Rate for Payer: Ohana Health Plan Medicare	$13.31
Rate for Payer: UnitedHealthcare Medicaid	$15.98
Rate for Payer: UnitedHealthcare Medicare	$13.31
Rate for Payer: University Health Alliance Commercial	$19.41

oxymetazoline 0.05% 15ml spray nasal [HHSC]

Facility

$11.40

Service Code	NDC 00904571135
Hospital Charge Code	2500626
Hospital Revenue Code	250
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$11.06
Rate for Payer: AlohaCare Medicaid	$5.70
Rate for Payer: AlohaCare Medicare	$5.70
Rate for Payer: Cash Price	$7.41
Rate for Payer: Devoted Health Medicare	$6.27
Rate for Payer: Hawaii Medical Service Association Medicare	$5.70
Rate for Payer: Hawaii Western Management Group Commercial	$10.83
Rate for Payer: Health Management Network Commercial	$9.69
Rate for Payer: Humana Medicare	$5.70
Rate for Payer: Kaiser Permanente Commercial	$10.26
Rate for Payer: Kaiser Permanente Medicaid	$5.81
Rate for Payer: Kaiser Permanente Medicare	$5.70
Rate for Payer: MDX Hawaii PPO	$11.06
Rate for Payer: Ohana Health Plan Medicaid	$5.70
Rate for Payer: Ohana Health Plan Medicare	$5.70
Rate for Payer: UnitedHealthcare Medicaid	$6.84
Rate for Payer: UnitedHealthcare Medicare	$5.70
Rate for Payer: University Health Alliance Commercial	$8.31

oxymetazoline 0.05% 15ml spray nasal [HHSC]

Facility

$11.40

Service Code	NDC 00904571135
Hospital Charge Code	2500626
Hospital Revenue Code	250
Min. Negotiated Rate	$9.69
Max. Negotiated Rate	$11.06
Rate for Payer: Cash Price	$7.41
Rate for Payer: Health Management Network Commercial	$9.69
Rate for Payer: Kaiser Permanente Commercial	$10.26
Rate for Payer: MDX Hawaii PPO	$11.06

oxymetazoline 0.05% 15ml spray nasal [HHSC]

Facility

$27.96

Service Code	NDC 11523116706
Hospital Charge Code	2500626
Hospital Revenue Code	250
Min. Negotiated Rate	$23.77
Max. Negotiated Rate	$27.12
Rate for Payer: Cash Price	$18.17
Rate for Payer: Health Management Network Commercial	$23.77
Rate for Payer: Kaiser Permanente Commercial	$25.16
Rate for Payer: MDX Hawaii PPO	$27.12

oxytocin 10 unit/1 ml vial [HHSC]

Facility

$20.02

Service Code	HCPCS J2590
Hospital Charge Code	2500627
Hospital Revenue Code	250
Min. Negotiated Rate	$17.02
Max. Negotiated Rate	$19.42
Rate for Payer: Cash Price	$13.01
Rate for Payer: Cash Price	$6.51
Rate for Payer: Cash Price	$6.46
Rate for Payer: Cash Price	$15.61
Rate for Payer: Health Management Network Commercial	$8.51
Rate for Payer: Health Management Network Commercial	$17.02
Rate for Payer: Health Management Network Commercial	$20.42
Rate for Payer: Health Management Network Commercial	$8.45
Rate for Payer: Kaiser Permanente Commercial	$9.01
Rate for Payer: Kaiser Permanente Commercial	$8.95
Rate for Payer: Kaiser Permanente Commercial	$21.62
Rate for Payer: Kaiser Permanente Commercial	$18.02
Rate for Payer: MDX Hawaii PPO	$9.71
Rate for Payer: MDX Hawaii PPO	$23.30
Rate for Payer: MDX Hawaii PPO	$9.64
Rate for Payer: MDX Hawaii PPO	$19.42

Know your out-of-pocket cost for care.

All Charges