Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

succinylcholine 20 mg/mL Inj Sol [KMC]

Facility

$9.21

Service Code	HCPCS J0330
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$8.93
Rate for Payer: AlohaCare Medicaid	$4.61
Rate for Payer: AlohaCare Medicare	$3.87
Rate for Payer: Cash Price	$5.99
Rate for Payer: Cash Price	$5.99
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$8.47
Rate for Payer: Devoted Health Medicare	$3.87
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Medicare	$3.87
Rate for Payer: Hawaii Western Management Group Commercial	$8.75
Rate for Payer: Health Management Network Commercial	$7.83
Rate for Payer: Humana Medicare	$3.87
Rate for Payer: Kaiser Permanente Commercial	$8.29
Rate for Payer: Kaiser Permanente Medicaid	$4.70
Rate for Payer: Kaiser Permanente Medicare	$3.87
Rate for Payer: MDX Hawaii PPO	$8.93
Rate for Payer: Ohana Health Plan Medicaid	$3.87
Rate for Payer: Ohana Health Plan Medicare	$3.87
Rate for Payer: UnitedHealthcare Medicaid	$5.53
Rate for Payer: UnitedHealthcare Medicare	$3.87
Rate for Payer: University Health Alliance Commercial	$6.71

succinylcholine 20 mg/mL Inj Sol [KMC]

Facility

$9.21

Service Code	HCPCS J0330
Hospital Revenue Code	636
Min. Negotiated Rate	$7.83
Max. Negotiated Rate	$8.93
Rate for Payer: Cash Price	$5.99
Rate for Payer: Health Management Network Commercial	$7.83
Rate for Payer: Kaiser Permanente Commercial	$8.29
Rate for Payer: MDX Hawaii PPO	$8.93

sucralfate 1 g/10 mL Oral Susp [KMC]

Facility

$4.34

Service Code	NDC 00121097494
Hospital Revenue Code	250
Min. Negotiated Rate	$3.69
Max. Negotiated Rate	$4.21
Rate for Payer: Cash Price	$2.82
Rate for Payer: Health Management Network Commercial	$3.69
Rate for Payer: Kaiser Permanente Commercial	$3.91
Rate for Payer: MDX Hawaii PPO	$4.21

sucralfate 1 g/10 mL Oral Susp [KMC]

Facility

$4.34

Service Code	NDC 00121097494
Hospital Revenue Code	250
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$4.21
Rate for Payer: AlohaCare Medicaid	$2.17
Rate for Payer: AlohaCare Medicare	$1.82
Rate for Payer: Cash Price	$2.82
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.99
Rate for Payer: Devoted Health Medicare	$1.82
Rate for Payer: Hawaii Medical Service Association Medicare	$1.82
Rate for Payer: Hawaii Western Management Group Commercial	$4.12
Rate for Payer: Health Management Network Commercial	$3.69
Rate for Payer: Humana Medicare	$1.82
Rate for Payer: Kaiser Permanente Commercial	$3.91
Rate for Payer: Kaiser Permanente Medicaid	$2.21
Rate for Payer: Kaiser Permanente Medicare	$1.82
Rate for Payer: MDX Hawaii PPO	$4.21
Rate for Payer: Ohana Health Plan Medicaid	$1.82
Rate for Payer: Ohana Health Plan Medicare	$1.82
Rate for Payer: UnitedHealthcare Medicaid	$2.60
Rate for Payer: UnitedHealthcare Medicare	$1.82
Rate for Payer: University Health Alliance Commercial	$3.16

sucralfate 1 gm Tab [KMC]

Facility

$3.00

Service Code	NDC 59762040101
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

sucralfate 1 gm Tab [KMC]

Facility

$3.00

Service Code	NDC 59762040101
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

SUCTION CANISTERS INNER

Facility

$7.00

Hospital Charge Code	8299
Hospital Revenue Code	270
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

SUCTION CANISTERS INNER

Facility

$7.00

Hospital Charge Code	8299
Hospital Revenue Code	270
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$2.94
Rate for Payer: Cash Price	$4.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.44
Rate for Payer: Devoted Health Medicare	$2.94
Rate for Payer: Hawaii Medical Service Association Medicare	$2.94
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$2.94
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$2.94
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$2.94
Rate for Payer: Ohana Health Plan Medicare	$2.94
Rate for Payer: UnitedHealthcare Medicare	$2.94
Rate for Payer: University Health Alliance Commercial	$5.10

SUCTION TUBING

Facility

$6.00

Hospital Charge Code	8301
Hospital Revenue Code	270
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$2.52
Rate for Payer: Cash Price	$3.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.52
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.52
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$2.52
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$2.52
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$2.52
Rate for Payer: Ohana Health Plan Medicare	$2.52
Rate for Payer: UnitedHealthcare Medicare	$2.52
Rate for Payer: University Health Alliance Commercial	$4.37

SUCTION TUBING

Facility

$6.00

Hospital Charge Code	8301
Hospital Revenue Code	270
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

SUICIDE RISK ASSESSED

Professional

Both

$0.01

Service Code	HCPCS 3085F
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$290.48
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

sulfamethoxazole-trimethoprim 200-40 mg/5 mL Oral Susp [KMC]

Facility

$1.82

Service Code	NDC 65862049647
Hospital Revenue Code	250
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$1.77
Rate for Payer: Cash Price	$1.18
Rate for Payer: Health Management Network Commercial	$1.55
Rate for Payer: Kaiser Permanente Commercial	$1.64
Rate for Payer: MDX Hawaii PPO	$1.77

sulfamethoxazole-trimethoprim 200-40 mg/5 mL Oral Susp [KMC]

Facility

$1.82

Service Code	NDC 65862049647
Hospital Revenue Code	250
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.77
Rate for Payer: AlohaCare Medicaid	$0.91
Rate for Payer: AlohaCare Medicare	$0.76
Rate for Payer: Cash Price	$1.18
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.67
Rate for Payer: Devoted Health Medicare	$0.76
Rate for Payer: Hawaii Medical Service Association Medicare	$0.76
Rate for Payer: Hawaii Western Management Group Commercial	$1.73
Rate for Payer: Health Management Network Commercial	$1.55
Rate for Payer: Humana Medicare	$0.76
Rate for Payer: Kaiser Permanente Commercial	$1.64
Rate for Payer: Kaiser Permanente Medicaid	$0.93
Rate for Payer: Kaiser Permanente Medicare	$0.76
Rate for Payer: MDX Hawaii PPO	$1.77
Rate for Payer: Ohana Health Plan Medicaid	$0.76
Rate for Payer: Ohana Health Plan Medicare	$0.76
Rate for Payer: UnitedHealthcare Medicaid	$1.09
Rate for Payer: UnitedHealthcare Medicare	$0.76
Rate for Payer: University Health Alliance Commercial	$1.33

sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [KMC]

Facility

$5.61

Service Code	NDC 57237023301
Hospital Revenue Code	250
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$5.44
Rate for Payer: AlohaCare Medicaid	$2.81
Rate for Payer: AlohaCare Medicare	$2.36
Rate for Payer: Cash Price	$3.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.16
Rate for Payer: Devoted Health Medicare	$2.36
Rate for Payer: Hawaii Medical Service Association Medicare	$2.36
Rate for Payer: Hawaii Western Management Group Commercial	$5.33
Rate for Payer: Health Management Network Commercial	$4.77
Rate for Payer: Humana Medicare	$2.36
Rate for Payer: Kaiser Permanente Commercial	$5.05
Rate for Payer: Kaiser Permanente Medicaid	$2.86
Rate for Payer: Kaiser Permanente Medicare	$2.36
Rate for Payer: MDX Hawaii PPO	$5.44
Rate for Payer: Ohana Health Plan Medicaid	$2.36
Rate for Payer: Ohana Health Plan Medicare	$2.36
Rate for Payer: UnitedHealthcare Medicaid	$3.37
Rate for Payer: UnitedHealthcare Medicare	$2.36
Rate for Payer: University Health Alliance Commercial	$4.09

sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [KMC]

Facility

$5.61

Service Code	NDC 57237023301
Hospital Revenue Code	250
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$5.44
Rate for Payer: Cash Price	$3.65
Rate for Payer: Health Management Network Commercial	$4.77
Rate for Payer: Kaiser Permanente Commercial	$5.05
Rate for Payer: MDX Hawaii PPO	$5.44

sulfaSALAzine 500 mg DR tab [KMC]

Facility

$9.89

Service Code	NDC 00013010250
Hospital Revenue Code	250
Min. Negotiated Rate	$8.41
Max. Negotiated Rate	$9.59
Rate for Payer: Cash Price	$6.43
Rate for Payer: Health Management Network Commercial	$8.41
Rate for Payer: Kaiser Permanente Commercial	$8.90
Rate for Payer: MDX Hawaii PPO	$9.59

sulfaSALAzine 500 mg DR tab [KMC]

Facility

$9.89

Service Code	NDC 00013010250
Hospital Revenue Code	250
Min. Negotiated Rate	$4.15
Max. Negotiated Rate	$9.59
Rate for Payer: AlohaCare Medicaid	$4.95
Rate for Payer: AlohaCare Medicare	$4.15
Rate for Payer: Cash Price	$6.43
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9.10
Rate for Payer: Devoted Health Medicare	$4.15
Rate for Payer: Hawaii Medical Service Association Medicare	$4.15
Rate for Payer: Hawaii Western Management Group Commercial	$9.40
Rate for Payer: Health Management Network Commercial	$8.41
Rate for Payer: Humana Medicare	$4.15
Rate for Payer: Kaiser Permanente Commercial	$8.90
Rate for Payer: Kaiser Permanente Medicaid	$5.04
Rate for Payer: Kaiser Permanente Medicare	$4.15
Rate for Payer: MDX Hawaii PPO	$9.59
Rate for Payer: Ohana Health Plan Medicaid	$4.15
Rate for Payer: Ohana Health Plan Medicare	$4.15
Rate for Payer: UnitedHealthcare Medicaid	$5.93
Rate for Payer: UnitedHealthcare Medicare	$4.15
Rate for Payer: University Health Alliance Commercial	$7.21

sulfaSALAzine 500 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 59762500005
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

sulfaSALAzine 500 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 59762500005
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

SUMAtriptan 100 mg Tab [KMC]

Facility

$100.56

Service Code	NDC 16714053311
Hospital Revenue Code	250
Min. Negotiated Rate	$85.48
Max. Negotiated Rate	$97.54
Rate for Payer: Cash Price	$65.36
Rate for Payer: Health Management Network Commercial	$85.48
Rate for Payer: Kaiser Permanente Commercial	$90.50
Rate for Payer: MDX Hawaii PPO	$97.54

SUMAtriptan 100 mg Tab [KMC]

Facility

$100.56

Service Code	NDC 16714053311
Hospital Revenue Code	250
Min. Negotiated Rate	$42.24
Max. Negotiated Rate	$97.54
Rate for Payer: AlohaCare Medicaid	$50.28
Rate for Payer: AlohaCare Medicare	$42.24
Rate for Payer: Cash Price	$65.36
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$92.52
Rate for Payer: Devoted Health Medicare	$42.24
Rate for Payer: Hawaii Medical Service Association Medicare	$42.24
Rate for Payer: Hawaii Western Management Group Commercial	$95.53
Rate for Payer: Health Management Network Commercial	$85.48
Rate for Payer: Humana Medicare	$42.24
Rate for Payer: Kaiser Permanente Commercial	$90.50
Rate for Payer: Kaiser Permanente Medicaid	$51.29
Rate for Payer: Kaiser Permanente Medicare	$42.24
Rate for Payer: MDX Hawaii PPO	$97.54
Rate for Payer: Ohana Health Plan Medicaid	$42.24
Rate for Payer: Ohana Health Plan Medicare	$42.24
Rate for Payer: UnitedHealthcare Medicaid	$60.34
Rate for Payer: UnitedHealthcare Medicare	$42.24
Rate for Payer: University Health Alliance Commercial	$73.30

SUMAtriptan 25 mg Tab [KMC]

Facility

$108.21

Service Code	NDC 16714079601
Hospital Revenue Code	250
Min. Negotiated Rate	$45.45
Max. Negotiated Rate	$104.96
Rate for Payer: AlohaCare Medicaid	$54.10
Rate for Payer: AlohaCare Medicare	$45.45
Rate for Payer: Cash Price	$70.34
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$99.55
Rate for Payer: Devoted Health Medicare	$45.45
Rate for Payer: Hawaii Medical Service Association Medicare	$45.45
Rate for Payer: Hawaii Western Management Group Commercial	$102.80
Rate for Payer: Health Management Network Commercial	$91.98
Rate for Payer: Humana Medicare	$45.45
Rate for Payer: Kaiser Permanente Commercial	$97.39
Rate for Payer: Kaiser Permanente Medicaid	$55.19
Rate for Payer: Kaiser Permanente Medicare	$45.45
Rate for Payer: MDX Hawaii PPO	$104.96
Rate for Payer: Ohana Health Plan Medicaid	$45.45
Rate for Payer: Ohana Health Plan Medicare	$45.45
Rate for Payer: UnitedHealthcare Medicaid	$64.93
Rate for Payer: UnitedHealthcare Medicare	$45.45
Rate for Payer: University Health Alliance Commercial	$78.87

SUMAtriptan 25 mg Tab [KMC]

Facility

$108.21

Service Code	NDC 16714079601
Hospital Revenue Code	250
Min. Negotiated Rate	$91.98
Max. Negotiated Rate	$104.96
Rate for Payer: Cash Price	$70.34
Rate for Payer: Health Management Network Commercial	$91.98
Rate for Payer: Kaiser Permanente Commercial	$97.39
Rate for Payer: MDX Hawaii PPO	$104.96

SUMAtriptan 50 mg Tab [KMC]

Facility

$100.56

Service Code	NDC 55111029236
Hospital Revenue Code	250
Min. Negotiated Rate	$85.48
Max. Negotiated Rate	$97.54
Rate for Payer: Cash Price	$65.36
Rate for Payer: Health Management Network Commercial	$85.48
Rate for Payer: Kaiser Permanente Commercial	$90.50
Rate for Payer: MDX Hawaii PPO	$97.54

SUMAtriptan 50 mg Tab [KMC]

Facility

$100.56

Service Code	NDC 55111029236
Hospital Revenue Code	250
Min. Negotiated Rate	$42.24
Max. Negotiated Rate	$97.54
Rate for Payer: AlohaCare Medicaid	$50.28
Rate for Payer: AlohaCare Medicare	$42.24
Rate for Payer: Cash Price	$65.36
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$92.52
Rate for Payer: Devoted Health Medicare	$42.24
Rate for Payer: Hawaii Medical Service Association Medicare	$42.24
Rate for Payer: Hawaii Western Management Group Commercial	$95.53
Rate for Payer: Health Management Network Commercial	$85.48
Rate for Payer: Humana Medicare	$42.24
Rate for Payer: Kaiser Permanente Commercial	$90.50
Rate for Payer: Kaiser Permanente Medicaid	$51.29
Rate for Payer: Kaiser Permanente Medicare	$42.24
Rate for Payer: MDX Hawaii PPO	$97.54
Rate for Payer: Ohana Health Plan Medicaid	$42.24
Rate for Payer: Ohana Health Plan Medicare	$42.24
Rate for Payer: UnitedHealthcare Medicaid	$60.34
Rate for Payer: UnitedHealthcare Medicare	$42.24
Rate for Payer: University Health Alliance Commercial	$73.30

Know your out-of-pocket cost for care.

All Charges