Kau Hospital

All Charges

Charge

Type

Setting

Price

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 1 GRAM TABLET [11442]

Facility

$2.00

Service Code	NDC 60687069511
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

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 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	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

SUCRALFATE 1 GRAM TABLET [11442]

Facility

$2.00

Service Code	NDC 60687069501
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
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

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	$72.23
Max. Negotiated Rate	$226.01
Rate for Payer: AlohaCare Medicaid	$116.50
Rate for Payer: AlohaCare Medicare	$72.23
Rate for Payer: Cash Price	$139.80
Rate for Payer: Devoted Health Medicare	$79.22
Rate for Payer: Hawaii Medical Service Association Medicare	$72.23
Rate for Payer: Hawaii Western Management Group Commercial	$221.35
Rate for Payer: Health Management Network Commercial	$198.05
Rate for Payer: Humana Medicare	$72.23
Rate for Payer: Kaiser Permanente Commercial	$209.70
Rate for Payer: Kaiser Permanente Medicaid	$118.83
Rate for Payer: Kaiser Permanente Medicare	$72.23
Rate for Payer: MDX Hawaii PPO	$226.01
Rate for Payer: Ohana Health Plan Medicaid	$72.23
Rate for Payer: Ohana Health Plan Medicare	$72.23
Rate for Payer: UnitedHealthcare Medicare	$72.23
Rate for Payer: University Health Alliance Commercial	$169.83

SUCTN CANISTER SAFETOUCH

Facility

$91.00

Hospital Revenue Code	272
Min. Negotiated Rate	$28.21
Max. Negotiated Rate	$88.27
Rate for Payer: AlohaCare Medicaid	$45.50
Rate for Payer: AlohaCare Medicare	$28.21
Rate for Payer: Cash Price	$54.60
Rate for Payer: Devoted Health Medicare	$30.94
Rate for Payer: Hawaii Medical Service Association Medicare	$28.21
Rate for Payer: Hawaii Western Management Group Commercial	$86.45
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Humana Medicare	$28.21
Rate for Payer: Kaiser Permanente Commercial	$81.90
Rate for Payer: Kaiser Permanente Medicaid	$46.41
Rate for Payer: Kaiser Permanente Medicare	$28.21
Rate for Payer: MDX Hawaii PPO	$88.27
Rate for Payer: Ohana Health Plan Medicaid	$28.21
Rate for Payer: Ohana Health Plan Medicare	$28.21
Rate for Payer: UnitedHealthcare Medicare	$28.21
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 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

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

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

Facility

$66.00

Service Code	NDC 24208031705
Hospital Revenue Code	637
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$64.02
Rate for Payer: AlohaCare Medicaid	$33.00
Rate for Payer: AlohaCare Medicare	$20.46
Rate for Payer: Cash Price	$39.60
Rate for Payer: Devoted Health Medicare	$22.44
Rate for Payer: Hawaii Medical Service Association Medicare	$20.46
Rate for Payer: Hawaii Western Management Group Commercial	$62.70
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Humana Medicare	$20.46
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: Kaiser Permanente Medicaid	$33.66
Rate for Payer: Kaiser Permanente Medicare	$20.46
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: Ohana Health Plan Medicaid	$20.46
Rate for Payer: Ohana Health Plan Medicare	$20.46
Rate for Payer: UnitedHealthcare Medicare	$20.46
Rate for Payer: University Health Alliance Commercial	$48.11

SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]

Facility

$214.00

Service Code	NDC 24208067004
Hospital Revenue Code	250
Min. Negotiated Rate	$181.90
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$128.40
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: MDX Hawaii PPO	$207.58

SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]

Facility

$214.00

Service Code	NDC 24208067004
Hospital Revenue Code	637
Min. Negotiated Rate	$66.34
Max. Negotiated Rate	$207.58
Rate for Payer: AlohaCare Medicaid	$107.00
Rate for Payer: AlohaCare Medicare	$66.34
Rate for Payer: Cash Price	$128.40
Rate for Payer: Devoted Health Medicare	$72.76
Rate for Payer: Hawaii Medical Service Association Medicare	$66.34
Rate for Payer: Hawaii Western Management Group Commercial	$203.30
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Humana Medicare	$66.34
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: Kaiser Permanente Medicaid	$109.14
Rate for Payer: Kaiser Permanente Medicare	$66.34
Rate for Payer: MDX Hawaii PPO	$207.58
Rate for Payer: Ohana Health Plan Medicaid	$66.34
Rate for Payer: Ohana Health Plan Medicare	$66.34
Rate for Payer: UnitedHealthcare Medicare	$66.34
Rate for Payer: University Health Alliance Commercial	$155.98

SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]

Facility

$319.00

Service Code	NDC 65862049647
Hospital Revenue Code	637
Min. Negotiated Rate	$98.89
Max. Negotiated Rate	$309.43
Rate for Payer: AlohaCare Medicaid	$159.50
Rate for Payer: AlohaCare Medicare	$98.89
Rate for Payer: Cash Price	$191.40
Rate for Payer: Devoted Health Medicare	$108.46
Rate for Payer: Hawaii Medical Service Association Medicare	$98.89
Rate for Payer: Hawaii Western Management Group Commercial	$303.05
Rate for Payer: Health Management Network Commercial	$271.15
Rate for Payer: Humana Medicare	$98.89
Rate for Payer: Kaiser Permanente Commercial	$287.10
Rate for Payer: Kaiser Permanente Medicaid	$162.69
Rate for Payer: Kaiser Permanente Medicare	$98.89
Rate for Payer: MDX Hawaii PPO	$309.43
Rate for Payer: Ohana Health Plan Medicaid	$98.89
Rate for Payer: Ohana Health Plan Medicare	$98.89
Rate for Payer: UnitedHealthcare Medicare	$98.89
Rate for Payer: University Health Alliance Commercial	$232.52

SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]

Facility

$319.00

Service Code	NDC 65862049647
Hospital Revenue Code	250
Min. Negotiated Rate	$271.15
Max. Negotiated Rate	$309.43
Rate for Payer: Cash Price	$191.40
Rate for Payer: Health Management Network Commercial	$271.15
Rate for Payer: Kaiser Permanente Commercial	$287.10
Rate for Payer: MDX Hawaii PPO	$309.43

SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION [7556]

Facility

$53.00

Service Code	NDC 00703951403
Hospital Revenue Code	250
Min. Negotiated Rate	$45.05
Max. Negotiated Rate	$51.41
Rate for Payer: Cash Price	$31.80
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Health Management Network Commercial	$45.05
Rate for Payer: Kaiser Permanente Commercial	$47.70
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$51.41
Rate for Payer: MDX Hawaii PPO	$26.19

SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION [7556]

Facility

$54.00

Service Code	NDC 70069036201
Hospital Revenue Code	250
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$32.40
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: MDX Hawaii PPO	$52.38

SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION [7556]

Facility

$54.00

Service Code	NDC 70069036210
Hospital Revenue Code	250
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$32.40
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: MDX Hawaii PPO	$52.38

SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]

Facility

$2.00

Service Code	NDC 60687060311
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]

Facility

$2.00

Service Code	NDC 60687060365
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

SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]

Facility

$3.00

Service Code	NDC 65862041901
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
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

Know your out-of-pocket cost for care.

All Charges