Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$33.00

Service Code	NDC 60687073808
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: MDX Hawaii PPO	$32.01

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$33.00

Service Code	NDC 60687073808
Hospital Revenue Code	637
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$25.08
Rate for Payer: Cash Price	$19.80
Rate for Payer: Devoted Health Medicare	$27.72
Rate for Payer: Hawaii Medical Service Association Medicare	$25.08
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$25.08
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$25.08
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$25.08
Rate for Payer: Ohana Health Plan Medicare	$25.08
Rate for Payer: UnitedHealthcare Medicare	$25.08
Rate for Payer: University Health Alliance Commercial	$24.05

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$33.00

Service Code	NDC 60687073842
Hospital Revenue Code	637
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$25.08
Rate for Payer: Cash Price	$19.80
Rate for Payer: Devoted Health Medicare	$27.72
Rate for Payer: Hawaii Medical Service Association Medicare	$25.08
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$25.08
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$25.08
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$25.08
Rate for Payer: Ohana Health Plan Medicare	$25.08
Rate for Payer: UnitedHealthcare Medicare	$25.08
Rate for Payer: University Health Alliance Commercial	$24.05

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$26.00

Service Code	NDC 50268074511
Hospital Revenue Code	637
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$25.22
Rate for Payer: AlohaCare Medicaid	$13.00
Rate for Payer: AlohaCare Medicare	$19.76
Rate for Payer: Cash Price	$15.60
Rate for Payer: Devoted Health Medicare	$21.84
Rate for Payer: Hawaii Medical Service Association Medicare	$19.76
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Humana Medicare	$19.76
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: Kaiser Permanente Medicare	$19.76
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: Ohana Health Plan Medicaid	$19.76
Rate for Payer: Ohana Health Plan Medicare	$19.76
Rate for Payer: UnitedHealthcare Medicare	$19.76
Rate for Payer: University Health Alliance Commercial	$18.95

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$22.00

Service Code	NDC 68094004159
Hospital Revenue Code	637
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$21.34
Rate for Payer: AlohaCare Medicaid	$11.00
Rate for Payer: AlohaCare Medicare	$16.72
Rate for Payer: Cash Price	$13.20
Rate for Payer: Devoted Health Medicare	$18.48
Rate for Payer: Hawaii Medical Service Association Medicare	$16.72
Rate for Payer: Hawaii Western Management Group Commercial	$20.90
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Humana Medicare	$16.72
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: Kaiser Permanente Medicaid	$11.22
Rate for Payer: Kaiser Permanente Medicare	$16.72
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: Ohana Health Plan Medicaid	$16.72
Rate for Payer: Ohana Health Plan Medicare	$16.72
Rate for Payer: UnitedHealthcare Medicare	$16.72
Rate for Payer: University Health Alliance Commercial	$16.04

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$33.00

Service Code	NDC 68094004362
Hospital Revenue Code	637
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$25.08
Rate for Payer: Cash Price	$19.80
Rate for Payer: Devoted Health Medicare	$27.72
Rate for Payer: Hawaii Medical Service Association Medicare	$25.08
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$25.08
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$25.08
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$25.08
Rate for Payer: Ohana Health Plan Medicare	$25.08
Rate for Payer: UnitedHealthcare Medicare	$25.08
Rate for Payer: University Health Alliance Commercial	$24.05

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$26.00

Service Code	NDC 50268074511
Hospital Revenue Code	250
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: MDX Hawaii PPO	$25.22

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$33.00

Service Code	NDC 60687073842
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: MDX Hawaii PPO	$32.01

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$481.00

Service Code	NDC 58914017014
Hospital Revenue Code	637
Min. Negotiated Rate	$240.50
Max. Negotiated Rate	$466.57
Rate for Payer: AlohaCare Medicaid	$240.50
Rate for Payer: AlohaCare Medicare	$365.56
Rate for Payer: Cash Price	$288.60
Rate for Payer: Devoted Health Medicare	$404.04
Rate for Payer: Hawaii Medical Service Association Medicare	$365.56
Rate for Payer: Hawaii Western Management Group Commercial	$456.95
Rate for Payer: Health Management Network Commercial	$408.85
Rate for Payer: Humana Medicare	$365.56
Rate for Payer: Kaiser Permanente Commercial	$432.90
Rate for Payer: Kaiser Permanente Medicaid	$245.31
Rate for Payer: Kaiser Permanente Medicare	$365.56
Rate for Payer: MDX Hawaii PPO	$466.57
Rate for Payer: Ohana Health Plan Medicaid	$365.56
Rate for Payer: Ohana Health Plan Medicare	$365.56
Rate for Payer: UnitedHealthcare Medicare	$365.56
Rate for Payer: University Health Alliance Commercial	$350.60

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$481.00

Service Code	NDC 58914017014
Hospital Revenue Code	250
Min. Negotiated Rate	$408.85
Max. Negotiated Rate	$466.57
Rate for Payer: Cash Price	$288.60
Rate for Payer: Health Management Network Commercial	$408.85
Rate for Payer: Kaiser Permanente Commercial	$432.90
Rate for Payer: MDX Hawaii PPO	$466.57

SUCRALFATE 1 GRAM TABLET [11442]

Facility

$2.00

Service Code	NDC 60687069501
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

SUCRALFATE 1 GRAM TABLET [11442]

Facility

$2.00

Service Code	NDC 60687069501
Hospital Revenue Code	637
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$1.52
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.52
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$1.52
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$1.52
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$1.52
Rate for Payer: Ohana Health Plan Medicare	$1.52
Rate for Payer: UnitedHealthcare Medicare	$1.52
Rate for Payer: University Health Alliance Commercial	$1.46

SUCRALFATE 1 GRAM TABLET [11442]

Facility

$2.00

Service Code	NDC 60687069511
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

SUCRALFATE 1 GRAM TABLET [11442]

Facility

$2.00

Service Code	NDC 51079075320
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

SUCRALFATE 1 GRAM TABLET [11442]

Facility

$2.00

Service Code	NDC 51079075320
Hospital Revenue Code	637
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$1.52
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.52
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$1.52
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$1.52
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$1.52
Rate for Payer: Ohana Health Plan Medicare	$1.52
Rate for Payer: UnitedHealthcare Medicare	$1.52
Rate for Payer: University Health Alliance Commercial	$1.46

SUCRALFATE 1 GRAM TABLET [11442]

Facility

$2.00

Service Code	NDC 60687069511
Hospital Revenue Code	637
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$1.52
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.52
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$1.52
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$1.52
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$1.52
Rate for Payer: Ohana Health Plan Medicare	$1.52
Rate for Payer: UnitedHealthcare Medicare	$1.52
Rate for Payer: University Health Alliance Commercial	$1.46

SUCTION IRRIGIGATOR WITH TIP

Facility

$233.00

Hospital Revenue Code	272
Min. Negotiated Rate	$198.05
Max. Negotiated Rate	$226.01
Rate for Payer: Cash Price	$139.80
Rate for Payer: Health Management Network Commercial	$198.05
Rate for Payer: Kaiser Permanente Commercial	$209.70
Rate for Payer: MDX Hawaii PPO	$226.01

SUCTION IRRIGIGATOR WITH TIP

Facility

$233.00

Hospital Revenue Code	272
Min. Negotiated Rate	$116.50
Max. Negotiated Rate	$226.01
Rate for Payer: AlohaCare Medicaid	$116.50
Rate for Payer: AlohaCare Medicare	$177.08
Rate for Payer: Cash Price	$139.80
Rate for Payer: Devoted Health Medicare	$195.72
Rate for Payer: Hawaii Medical Service Association Medicare	$177.08
Rate for Payer: Hawaii Western Management Group Commercial	$221.35
Rate for Payer: Health Management Network Commercial	$198.05
Rate for Payer: Humana Medicare	$177.08
Rate for Payer: Kaiser Permanente Commercial	$209.70
Rate for Payer: Kaiser Permanente Medicaid	$118.83
Rate for Payer: Kaiser Permanente Medicare	$177.08
Rate for Payer: MDX Hawaii PPO	$226.01
Rate for Payer: Ohana Health Plan Medicaid	$177.08
Rate for Payer: Ohana Health Plan Medicare	$177.08
Rate for Payer: UnitedHealthcare Medicare	$177.08
Rate for Payer: University Health Alliance Commercial	$169.83

SUCTN CANISTER SAFETOUCH

Facility

$91.00

Hospital Revenue Code	272
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$88.27
Rate for Payer: AlohaCare Medicaid	$45.50
Rate for Payer: AlohaCare Medicare	$69.16
Rate for Payer: Cash Price	$54.60
Rate for Payer: Devoted Health Medicare	$76.44
Rate for Payer: Hawaii Medical Service Association Medicare	$69.16
Rate for Payer: Hawaii Western Management Group Commercial	$86.45
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Humana Medicare	$69.16
Rate for Payer: Kaiser Permanente Commercial	$81.90
Rate for Payer: Kaiser Permanente Medicaid	$46.41
Rate for Payer: Kaiser Permanente Medicare	$69.16
Rate for Payer: MDX Hawaii PPO	$88.27
Rate for Payer: Ohana Health Plan Medicaid	$69.16
Rate for Payer: Ohana Health Plan Medicare	$69.16
Rate for Payer: UnitedHealthcare Medicare	$69.16
Rate for Payer: University Health Alliance Commercial	$66.33

SUCTN CANISTER SAFETOUCH

Facility

$91.00

Hospital Revenue Code	272
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Kaiser Permanente Commercial	$81.90
Rate for Payer: MDX Hawaii PPO	$88.27

SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION [131263]

Facility

$246.00

Service Code	NDC 00006542312
Hospital Revenue Code	250
Min. Negotiated Rate	$209.10
Max. Negotiated Rate	$238.62
Rate for Payer: Cash Price	$147.60
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: MDX Hawaii PPO	$238.62

SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION [131263]

Facility

$246.00

Service Code	NDC 00006542302
Hospital Revenue Code	250
Min. Negotiated Rate	$209.10
Max. Negotiated Rate	$238.62
Rate for Payer: Cash Price	$147.60
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: MDX Hawaii PPO	$238.62

SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS [70392]

Facility

$66.00

Service Code	NDC 24208031705
Hospital Revenue Code	637
Min. Negotiated Rate	$33.00
Max. Negotiated Rate	$64.02
Rate for Payer: AlohaCare Medicaid	$33.00
Rate for Payer: AlohaCare Medicare	$50.16
Rate for Payer: Cash Price	$39.60
Rate for Payer: Devoted Health Medicare	$55.44
Rate for Payer: Hawaii Medical Service Association Medicare	$50.16
Rate for Payer: Hawaii Western Management Group Commercial	$62.70
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Humana Medicare	$50.16
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: Kaiser Permanente Medicaid	$33.66
Rate for Payer: Kaiser Permanente Medicare	$50.16
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: Ohana Health Plan Medicaid	$50.16
Rate for Payer: Ohana Health Plan Medicare	$50.16
Rate for Payer: UnitedHealthcare Medicare	$50.16
Rate for Payer: University Health Alliance Commercial	$48.11

SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS [70392]

Facility

$66.00

Service Code	NDC 24208031705
Hospital Revenue Code	250
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$39.60
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: MDX Hawaii PPO	$64.02

SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]

Facility

$214.00

Service Code	NDC 24208067004
Hospital Revenue Code	637
Min. Negotiated Rate	$107.00
Max. Negotiated Rate	$207.58
Rate for Payer: AlohaCare Medicaid	$107.00
Rate for Payer: AlohaCare Medicare	$162.64
Rate for Payer: Cash Price	$128.40
Rate for Payer: Devoted Health Medicare	$179.76
Rate for Payer: Hawaii Medical Service Association Medicare	$162.64
Rate for Payer: Hawaii Western Management Group Commercial	$203.30
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Humana Medicare	$162.64
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: Kaiser Permanente Medicaid	$109.14
Rate for Payer: Kaiser Permanente Medicare	$162.64
Rate for Payer: MDX Hawaii PPO	$207.58
Rate for Payer: Ohana Health Plan Medicaid	$162.64
Rate for Payer: Ohana Health Plan Medicare	$162.64
Rate for Payer: UnitedHealthcare Medicare	$162.64
Rate for Payer: University Health Alliance Commercial	$155.98

Know your out-of-pocket cost for care.

All Charges