Kona Community Hospital

All Charges

Charge

Type

Setting

Price

OXCARBAZEPINE 300 MG PO TAB (0.5 TAB) = 150 MG

Facility

$14.41

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$12.25
Max. Negotiated Rate	$13.98
Rate for Payer: Cash Price	$9.37
Rate for Payer: Health Management Network Commercial	$12.25
Rate for Payer: MDX Hawaii PPO	$13.98

OXCARBAZEPINE 300 MG PO TAB (0.5 TAB) = 150 MG

Facility

$14.41

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$13.98
Rate for Payer: Cash Price	$9.37
Rate for Payer: Hawaii Western Management Group Commercial	$13.69
Rate for Payer: Health Management Network Commercial	$12.25
Rate for Payer: Kaiser Permanente Commercial	$9.08
Rate for Payer: Kaiser Permanente Medicaid	$7.35
Rate for Payer: MDX Hawaii PPO	$13.98
Rate for Payer: UnitedHealthcare Medicaid	$8.65
Rate for Payer: University Health Alliance Commercial	$10.50

OXCARBAZEPINE 300 MG PO TABLET

Facility

$15.21

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$12.93
Max. Negotiated Rate	$14.75
Rate for Payer: Cash Price	$9.89
Rate for Payer: Cash Price	$9.37
Rate for Payer: Cash Price	$3.03
Rate for Payer: Health Management Network Commercial	$12.93
Rate for Payer: Health Management Network Commercial	$12.25
Rate for Payer: Health Management Network Commercial	$3.96
Rate for Payer: MDX Hawaii PPO	$13.98
Rate for Payer: MDX Hawaii PPO	$4.52
Rate for Payer: MDX Hawaii PPO	$14.75

OXCARBAZEPINE 300 MG PO TABLET

Facility

$15.21

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.76
Max. Negotiated Rate	$14.75
Rate for Payer: Cash Price	$9.89
Rate for Payer: Cash Price	$9.37
Rate for Payer: Cash Price	$3.03
Rate for Payer: Hawaii Western Management Group Commercial	$4.43
Rate for Payer: Hawaii Western Management Group Commercial	$14.45
Rate for Payer: Hawaii Western Management Group Commercial	$13.69
Rate for Payer: Health Management Network Commercial	$12.25
Rate for Payer: Health Management Network Commercial	$12.93
Rate for Payer: Health Management Network Commercial	$3.96
Rate for Payer: Kaiser Permanente Commercial	$9.08
Rate for Payer: Kaiser Permanente Commercial	$9.58
Rate for Payer: Kaiser Permanente Commercial	$2.94
Rate for Payer: Kaiser Permanente Medicaid	$7.35
Rate for Payer: Kaiser Permanente Medicaid	$7.76
Rate for Payer: Kaiser Permanente Medicaid	$2.38
Rate for Payer: MDX Hawaii PPO	$13.98
Rate for Payer: MDX Hawaii PPO	$14.75
Rate for Payer: MDX Hawaii PPO	$4.52
Rate for Payer: UnitedHealthcare Medicaid	$9.13
Rate for Payer: UnitedHealthcare Medicaid	$2.80
Rate for Payer: UnitedHealthcare Medicaid	$8.65
Rate for Payer: University Health Alliance Commercial	$3.40
Rate for Payer: University Health Alliance Commercial	$10.50
Rate for Payer: University Health Alliance Commercial	$11.09

OXCARBAZEPINE 600 MG PO TABLET

Facility

$27.95

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$14.25
Max. Negotiated Rate	$27.11
Rate for Payer: Cash Price	$18.17
Rate for Payer: Hawaii Western Management Group Commercial	$26.55
Rate for Payer: Health Management Network Commercial	$23.76
Rate for Payer: Kaiser Permanente Commercial	$17.61
Rate for Payer: Kaiser Permanente Medicaid	$14.25
Rate for Payer: MDX Hawaii PPO	$27.11
Rate for Payer: UnitedHealthcare Medicaid	$16.77
Rate for Payer: University Health Alliance Commercial	$20.37

OXCARBAZEPINE 600 MG PO TABLET

Facility

$27.95

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$23.76
Max. Negotiated Rate	$27.11
Rate for Payer: Cash Price	$18.17
Rate for Payer: Health Management Network Commercial	$23.76
Rate for Payer: MDX Hawaii PPO	$27.11

OXYBUTYNIN CHLORIDE 5 MG PO TABLET

Facility

$2.42

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$2.35
Rate for Payer: Cash Price	$1.57
Rate for Payer: Health Management Network Commercial	$2.06
Rate for Payer: MDX Hawaii PPO	$2.35

OXYBUTYNIN CHLORIDE 5 MG PO TABLET

Facility

$2.42

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$2.35
Rate for Payer: Cash Price	$1.57
Rate for Payer: Hawaii Western Management Group Commercial	$2.30
Rate for Payer: Health Management Network Commercial	$2.06
Rate for Payer: Kaiser Permanente Commercial	$1.52
Rate for Payer: Kaiser Permanente Medicaid	$1.23
Rate for Payer: MDX Hawaii PPO	$2.35
Rate for Payer: UnitedHealthcare Medicaid	$1.45
Rate for Payer: University Health Alliance Commercial	$1.76

OXYCODONE 10 MG PO IMMEDIATE RELEASE TABLET

Facility

$4.74

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$4.60
Rate for Payer: Cash Price	$3.08
Rate for Payer: Health Management Network Commercial	$4.03
Rate for Payer: MDX Hawaii PPO	$4.60

OXYCODONE 10 MG PO IMMEDIATE RELEASE TABLET

Facility

$4.74

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$4.60
Rate for Payer: Cash Price	$3.08
Rate for Payer: Hawaii Western Management Group Commercial	$4.50
Rate for Payer: Health Management Network Commercial	$4.03
Rate for Payer: Kaiser Permanente Commercial	$2.99
Rate for Payer: Kaiser Permanente Medicaid	$2.42
Rate for Payer: MDX Hawaii PPO	$4.60
Rate for Payer: UnitedHealthcare Medicaid	$2.84
Rate for Payer: University Health Alliance Commercial	$3.45

OXYCODONE 10 MG PO TAB EXTENDED RELEASE 12 H

Facility

$32.11

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$27.29
Max. Negotiated Rate	$31.15
Rate for Payer: Cash Price	$20.87
Rate for Payer: Health Management Network Commercial	$27.29
Rate for Payer: MDX Hawaii PPO	$31.15

OXYCODONE 10 MG PO TAB EXTENDED RELEASE 12 H

Facility

$32.11

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$31.15
Rate for Payer: Cash Price	$20.87
Rate for Payer: Hawaii Western Management Group Commercial	$30.50
Rate for Payer: Health Management Network Commercial	$27.29
Rate for Payer: Kaiser Permanente Commercial	$20.23
Rate for Payer: Kaiser Permanente Medicaid	$16.38
Rate for Payer: MDX Hawaii PPO	$31.15
Rate for Payer: UnitedHealthcare Medicaid	$19.27
Rate for Payer: University Health Alliance Commercial	$23.40

OXYCODONE 15 MG PO TABLET

Facility

$10.33

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$5.27
Max. Negotiated Rate	$10.02
Rate for Payer: Cash Price	$6.71
Rate for Payer: Cash Price	$6.81
Rate for Payer: Hawaii Western Management Group Commercial	$9.81
Rate for Payer: Hawaii Western Management Group Commercial	$9.95
Rate for Payer: Health Management Network Commercial	$8.78
Rate for Payer: Health Management Network Commercial	$8.90
Rate for Payer: Kaiser Permanente Commercial	$6.51
Rate for Payer: Kaiser Permanente Commercial	$6.60
Rate for Payer: Kaiser Permanente Medicaid	$5.27
Rate for Payer: Kaiser Permanente Medicaid	$5.34
Rate for Payer: MDX Hawaii PPO	$10.02
Rate for Payer: MDX Hawaii PPO	$10.16
Rate for Payer: UnitedHealthcare Medicaid	$6.28
Rate for Payer: UnitedHealthcare Medicaid	$6.20
Rate for Payer: University Health Alliance Commercial	$7.53
Rate for Payer: University Health Alliance Commercial	$7.63

OXYCODONE 15 MG PO TABLET

Facility

$10.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$8.90
Max. Negotiated Rate	$10.16
Rate for Payer: Cash Price	$6.81
Rate for Payer: Cash Price	$6.71
Rate for Payer: Health Management Network Commercial	$8.78
Rate for Payer: Health Management Network Commercial	$8.90
Rate for Payer: MDX Hawaii PPO	$10.16
Rate for Payer: MDX Hawaii PPO	$10.02

OXYCODONE 20 MG PO TAB EXTENDED RELEASE 12 H

Facility

$62.01

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$52.71
Max. Negotiated Rate	$60.15
Rate for Payer: Cash Price	$40.31
Rate for Payer: Health Management Network Commercial	$52.71
Rate for Payer: MDX Hawaii PPO	$60.15

OXYCODONE 20 MG PO TAB EXTENDED RELEASE 12 H

Facility

$62.01

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$31.63
Max. Negotiated Rate	$60.15
Rate for Payer: Cash Price	$40.31
Rate for Payer: Hawaii Western Management Group Commercial	$58.91
Rate for Payer: Health Management Network Commercial	$52.71
Rate for Payer: Kaiser Permanente Commercial	$39.07
Rate for Payer: Kaiser Permanente Medicaid	$31.63
Rate for Payer: MDX Hawaii PPO	$60.15
Rate for Payer: UnitedHealthcare Medicaid	$37.21
Rate for Payer: University Health Alliance Commercial	$45.20

OXYCODONE 5 MG PO IMMEDIATE RELEASE TAB

Facility

$2.99

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$2.54
Max. Negotiated Rate	$2.90
Rate for Payer: Cash Price	$1.94
Rate for Payer: Health Management Network Commercial	$2.54
Rate for Payer: MDX Hawaii PPO	$2.90

OXYCODONE 5 MG PO IMMEDIATE RELEASE TAB

Facility

$2.99

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$2.90
Rate for Payer: Cash Price	$1.94
Rate for Payer: Hawaii Western Management Group Commercial	$2.84
Rate for Payer: Health Management Network Commercial	$2.54
Rate for Payer: Kaiser Permanente Commercial	$1.88
Rate for Payer: Kaiser Permanente Medicaid	$1.52
Rate for Payer: MDX Hawaii PPO	$2.90
Rate for Payer: UnitedHealthcare Medicaid	$1.79
Rate for Payer: University Health Alliance Commercial	$2.18

OXYCODONE-ACETAMINOPHEN 10-325 MG PO TABLET

Facility

$19.71

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$16.75
Max. Negotiated Rate	$19.12
Rate for Payer: Cash Price	$12.81
Rate for Payer: Health Management Network Commercial	$16.75
Rate for Payer: MDX Hawaii PPO	$19.12

OXYCODONE-ACETAMINOPHEN 10-325 MG PO TABLET

Facility

$19.71

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$10.05
Max. Negotiated Rate	$19.12
Rate for Payer: Cash Price	$12.81
Rate for Payer: Hawaii Western Management Group Commercial	$18.72
Rate for Payer: Health Management Network Commercial	$16.75
Rate for Payer: Kaiser Permanente Commercial	$12.42
Rate for Payer: Kaiser Permanente Medicaid	$10.05
Rate for Payer: MDX Hawaii PPO	$19.12
Rate for Payer: UnitedHealthcare Medicaid	$11.83
Rate for Payer: University Health Alliance Commercial	$14.37

OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABLET

Facility

$7.55

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$7.32
Rate for Payer: Cash Price	$4.91
Rate for Payer: Cash Price	$6.83
Rate for Payer: Hawaii Western Management Group Commercial	$7.17
Rate for Payer: Hawaii Western Management Group Commercial	$9.98
Rate for Payer: Health Management Network Commercial	$6.42
Rate for Payer: Health Management Network Commercial	$8.93
Rate for Payer: Kaiser Permanente Commercial	$6.62
Rate for Payer: Kaiser Permanente Commercial	$4.76
Rate for Payer: Kaiser Permanente Medicaid	$3.85
Rate for Payer: Kaiser Permanente Medicaid	$5.36
Rate for Payer: MDX Hawaii PPO	$10.19
Rate for Payer: MDX Hawaii PPO	$7.32
Rate for Payer: UnitedHealthcare Medicaid	$6.31
Rate for Payer: UnitedHealthcare Medicaid	$4.53
Rate for Payer: University Health Alliance Commercial	$7.66
Rate for Payer: University Health Alliance Commercial	$5.50

OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABLET

Facility

$10.51

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$8.93
Max. Negotiated Rate	$10.19
Rate for Payer: Cash Price	$6.83
Rate for Payer: Cash Price	$4.91
Rate for Payer: Health Management Network Commercial	$8.93
Rate for Payer: Health Management Network Commercial	$6.42
Rate for Payer: MDX Hawaii PPO	$10.19
Rate for Payer: MDX Hawaii PPO	$7.32

OXYMETAZOLINE 0.05 % NASAL NON-AER.SPRY

Facility

$40.43

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$34.37
Max. Negotiated Rate	$39.22
Rate for Payer: Cash Price	$26.28
Rate for Payer: Cash Price	$14.32
Rate for Payer: Cash Price	$25.43
Rate for Payer: Health Management Network Commercial	$34.37
Rate for Payer: Health Management Network Commercial	$33.26
Rate for Payer: Health Management Network Commercial	$18.73
Rate for Payer: MDX Hawaii PPO	$37.96
Rate for Payer: MDX Hawaii PPO	$21.37
Rate for Payer: MDX Hawaii PPO	$39.22

OXYMETAZOLINE 0.05 % NASAL NON-AER.SPRY

Facility

$22.03

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$11.24
Max. Negotiated Rate	$21.37
Rate for Payer: Cash Price	$14.32
Rate for Payer: Cash Price	$26.28
Rate for Payer: Cash Price	$25.43
Rate for Payer: Hawaii Western Management Group Commercial	$38.41
Rate for Payer: Hawaii Western Management Group Commercial	$37.17
Rate for Payer: Hawaii Western Management Group Commercial	$20.93
Rate for Payer: Health Management Network Commercial	$34.37
Rate for Payer: Health Management Network Commercial	$18.73
Rate for Payer: Health Management Network Commercial	$33.26
Rate for Payer: Kaiser Permanente Commercial	$13.88
Rate for Payer: Kaiser Permanente Commercial	$24.65
Rate for Payer: Kaiser Permanente Commercial	$25.47
Rate for Payer: Kaiser Permanente Medicaid	$19.96
Rate for Payer: Kaiser Permanente Medicaid	$11.24
Rate for Payer: Kaiser Permanente Medicaid	$20.62
Rate for Payer: MDX Hawaii PPO	$37.96
Rate for Payer: MDX Hawaii PPO	$21.37
Rate for Payer: MDX Hawaii PPO	$39.22
Rate for Payer: UnitedHealthcare Medicaid	$23.48
Rate for Payer: UnitedHealthcare Medicaid	$13.22
Rate for Payer: UnitedHealthcare Medicaid	$24.26
Rate for Payer: University Health Alliance Commercial	$16.06
Rate for Payer: University Health Alliance Commercial	$28.52
Rate for Payer: University Health Alliance Commercial	$29.47

OXYTOCIN 10 UNIT/ML INJ SOLN

Facility

$8.28

Service Code	HCPCS J2590
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$8.03
Rate for Payer: Cash Price	$5.38
Rate for Payer: Cash Price	$12.38
Rate for Payer: Cash Price	$12.38
Rate for Payer: Cash Price	$5.38
Rate for Payer: Hawaii Medical Service Association ABD	$0.55
Rate for Payer: Hawaii Medical Service Association ABD	$0.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.55
Rate for Payer: Hawaii Western Management Group Commercial	$18.10
Rate for Payer: Hawaii Western Management Group Commercial	$7.87
Rate for Payer: Health Management Network Commercial	$7.04
Rate for Payer: Health Management Network Commercial	$16.19
Rate for Payer: Kaiser Permanente Commercial	$5.22
Rate for Payer: Kaiser Permanente Commercial	$12.00
Rate for Payer: Kaiser Permanente Medicaid	$9.72
Rate for Payer: Kaiser Permanente Medicaid	$4.22
Rate for Payer: MDX Hawaii PPO	$18.48
Rate for Payer: MDX Hawaii PPO	$8.03
Rate for Payer: UnitedHealthcare Medicaid	$4.97
Rate for Payer: UnitedHealthcare Medicaid	$11.43
Rate for Payer: University Health Alliance Commercial	$6.04
Rate for Payer: University Health Alliance Commercial	$13.89

Know your out-of-pocket cost for care.

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