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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]

Facility

IP

$2.00

Service Code	NDC 60687060311
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

OP

$2.00

Service Code	NDC 60687060365
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

OP

$3.00

Service Code	NDC 65862041901
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [11599]

Facility

OP

$2.00

Service Code	NDC 60687061401
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 800 MG-TRIMETHOPRIM 160 MG TABLET [11599]

Facility

OP

$2.00

Service Code	NDC 00904272561
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 800 MG-TRIMETHOPRIM 160 MG TABLET [11599]

Facility

IP

$2.00

Service Code	NDC 60687061411
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 800 MG-TRIMETHOPRIM 160 MG TABLET [11599]

Facility

IP

$2.00

Service Code	NDC 00904272561
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 800 MG-TRIMETHOPRIM 160 MG TABLET [11599]

Facility

IP

$2.00

Service Code	NDC 60687061401
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 800 MG-TRIMETHOPRIM 160 MG TABLET [11599]

Facility

OP

$2.00

Service Code	NDC 60687061411
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/TRIMETHOPRIM 800/160 MG TABLETS (BACTRIM DS) (TAKE HOME) [4080340]

Facility

OP

$15.00

Service Code	NDC 00004080128
Hospital Revenue Code	253
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$4.65
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$5.10
Rate for Payer: Hawaii Medical Service Association Medicare	$4.65
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$4.65
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$4.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$4.65
Rate for Payer: Ohana Health Plan Medicare	$4.65
Rate for Payer: UnitedHealthcare Medicare	$4.65
Rate for Payer: University Health Alliance Commercial	$10.93

SULFAMETHOXAZOLE/TRIMETHOPRIM 800/160 MG TABLETS (BACTRIM DS) (TAKE HOME) [4080340]

Facility

IP

$15.00

Service Code	NDC 00004080128
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

SULFAMETH/TMP 200-40 MG/5 ML SUSPENSION (BACTRIM) (120 ML) (TAKE HOME) [4080398]

Facility

OP

$15.00

Service Code	NDC 00004080186
Hospital Revenue Code	253
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$4.65
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$5.10
Rate for Payer: Hawaii Medical Service Association Medicare	$4.65
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$4.65
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$4.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$4.65
Rate for Payer: Ohana Health Plan Medicare	$4.65
Rate for Payer: UnitedHealthcare Medicare	$4.65
Rate for Payer: University Health Alliance Commercial	$10.93

SULFAMETH/TMP 200-40 MG/5 ML SUSPENSION (BACTRIM) (120 ML) (TAKE HOME) [4080398]

Facility

IP

$15.00

Service Code	NDC 00004080186
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

SULFASALAZINE 500 MG TABLET [7562]

Facility

IP

$1.00

Service Code	NDC 59762500005
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

SULFASALAZINE 500 MG TABLET [7562]

Facility

OP

$1.00

Service Code	NDC 59762500005
Hospital Revenue Code	637
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.31
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.34
Rate for Payer: Hawaii Medical Service Association Medicare	$0.31
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.31
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.31
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.31
Rate for Payer: Ohana Health Plan Medicare	$0.31
Rate for Payer: UnitedHealthcare Medicare	$0.31
Rate for Payer: University Health Alliance Commercial	$0.73

SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97343]

Facility

IP

$33.00

Service Code	NDC 55150017301
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

SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97343]

Facility

IP

$128.00

Service Code	NDC 64679072801
Hospital Revenue Code	250
Min. Negotiated Rate	$108.80
Max. Negotiated Rate	$124.16
Rate for Payer: Cash Price	$76.80
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Kaiser Permanente Commercial	$115.20
Rate for Payer: MDX Hawaii PPO	$124.16

SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97343]

Facility

IP

$36.00

Service Code	NDC 00143963805
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

SUNDT CAR SHNT 3.5MM/NL8505079

Facility

OP

$2,470.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$765.70
Max. Negotiated Rate	$2,395.90
Rate for Payer: AlohaCare Medicaid	$1,235.00
Rate for Payer: AlohaCare Medicare	$765.70
Rate for Payer: Cash Price	$1,482.00
Rate for Payer: Devoted Health Medicare	$839.80
Rate for Payer: Hawaii Medical Service Association Medicare	$765.70
Rate for Payer: Hawaii Western Management Group Commercial	$2,346.50
Rate for Payer: Health Management Network Commercial	$2,099.50
Rate for Payer: Humana Medicare	$765.70
Rate for Payer: Kaiser Permanente Commercial	$2,223.00
Rate for Payer: Kaiser Permanente Medicaid	$1,259.70
Rate for Payer: Kaiser Permanente Medicare	$765.70
Rate for Payer: MDX Hawaii PPO	$2,395.90
Rate for Payer: Ohana Health Plan Medicaid	$765.70
Rate for Payer: Ohana Health Plan Medicare	$765.70
Rate for Payer: UnitedHealthcare Medicare	$765.70
Rate for Payer: University Health Alliance Commercial	$1,800.38

SUNDT CAR SHNT 3.5MM/NL8505079

Facility

IP

$2,470.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$2,099.50
Max. Negotiated Rate	$2,395.90
Rate for Payer: Cash Price	$1,482.00
Rate for Payer: Health Management Network Commercial	$2,099.50
Rate for Payer: Kaiser Permanente Commercial	$2,223.00
Rate for Payer: MDX Hawaii PPO	$2,395.90

SUNDT CAR SHNT 3MM/NL8505070

Facility

IP

$2,000.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$1,700.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00

SUNDT CAR SHNT 3MM/NL8505070

Facility

OP

$2,000.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$620.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$620.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Devoted Health Medicare	$680.00
Rate for Payer: Hawaii Medical Service Association Medicare	$620.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,900.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$620.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$620.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$620.00
Rate for Payer: Ohana Health Plan Medicare	$620.00
Rate for Payer: UnitedHealthcare Medicare	$620.00
Rate for Payer: University Health Alliance Commercial	$1,457.80

SUNDT EXT ENDART SHUNT 3MM X

Facility

IP

$1,393.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$1,184.05
Max. Negotiated Rate	$1,351.21
Rate for Payer: Cash Price	$835.80
Rate for Payer: Health Management Network Commercial	$1,184.05
Rate for Payer: Kaiser Permanente Commercial	$1,253.70
Rate for Payer: MDX Hawaii PPO	$1,351.21

SUNDT EXT ENDART SHUNT 3MM X

Facility

OP

$1,393.00

Service Code	HCPCS C1889
Hospital Revenue Code	272
Min. Negotiated Rate	$431.83
Max. Negotiated Rate	$1,351.21
Rate for Payer: AlohaCare Medicaid	$696.50
Rate for Payer: AlohaCare Medicare	$431.83
Rate for Payer: Cash Price	$835.80
Rate for Payer: Devoted Health Medicare	$473.62
Rate for Payer: Hawaii Medical Service Association Medicare	$431.83
Rate for Payer: Hawaii Western Management Group Commercial	$1,323.35
Rate for Payer: Health Management Network Commercial	$1,184.05
Rate for Payer: Humana Medicare	$431.83
Rate for Payer: Kaiser Permanente Commercial	$1,253.70
Rate for Payer: Kaiser Permanente Medicaid	$710.43
Rate for Payer: Kaiser Permanente Medicare	$431.83
Rate for Payer: MDX Hawaii PPO	$1,351.21
Rate for Payer: Ohana Health Plan Medicaid	$431.83
Rate for Payer: Ohana Health Plan Medicare	$431.83
Rate for Payer: UnitedHealthcare Medicare	$431.83
Rate for Payer: University Health Alliance Commercial	$1,015.36

SUPERIOR CLAVICLE 8H RT 628028

Facility

IP

$3,450.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,932.00
Max. Negotiated Rate	$3,346.50
Rate for Payer: Cash Price	$2,070.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,415.00
Rate for Payer: Health Management Network Commercial	$2,932.50
Rate for Payer: Kaiser Permanente Commercial	$3,105.00
Rate for Payer: MDX Hawaii PPO	$3,346.50
Rate for Payer: University Health Alliance Commercial	$1,932.00

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