Kona Community Hospital

All Charges

Charge

Type

Setting

Price

SUGAMMADEX 100 MG/ML IV SOLN

Facility

$522.63

Service Code	HCPCS J3490
Hospital Revenue Code	250
Min. Negotiated Rate	$444.24
Max. Negotiated Rate	$506.95
Rate for Payer: Cash Price	$339.71
Rate for Payer: Health Management Network Commercial	$444.24
Rate for Payer: MDX Hawaii PPO	$506.95

SULFACETAMIDE SODIUM 10 % OPHT DROP

Facility

$310.44

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$158.32
Max. Negotiated Rate	$301.13
Rate for Payer: Cash Price	$201.79
Rate for Payer: Hawaii Western Management Group Commercial	$294.92
Rate for Payer: Health Management Network Commercial	$263.87
Rate for Payer: Kaiser Permanente Commercial	$195.58
Rate for Payer: Kaiser Permanente Medicaid	$158.32
Rate for Payer: MDX Hawaii PPO	$301.13
Rate for Payer: UnitedHealthcare Medicaid	$186.26
Rate for Payer: University Health Alliance Commercial	$226.28

SULFACETAMIDE SODIUM 10 % OPHT DROP

Facility

$310.44

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$263.87
Max. Negotiated Rate	$301.13
Rate for Payer: Cash Price	$201.79
Rate for Payer: Health Management Network Commercial	$263.87
Rate for Payer: MDX Hawaii PPO	$301.13

SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML PO SUSP

Facility

$26.39

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$13.46
Max. Negotiated Rate	$25.60
Rate for Payer: Cash Price	$17.15
Rate for Payer: Cash Price	$446.41
Rate for Payer: Hawaii Western Management Group Commercial	$25.07
Rate for Payer: Hawaii Western Management Group Commercial	$652.45
Rate for Payer: Health Management Network Commercial	$22.43
Rate for Payer: Health Management Network Commercial	$583.77
Rate for Payer: Kaiser Permanente Commercial	$16.63
Rate for Payer: Kaiser Permanente Commercial	$432.68
Rate for Payer: Kaiser Permanente Medicaid	$13.46
Rate for Payer: Kaiser Permanente Medicaid	$350.26
Rate for Payer: MDX Hawaii PPO	$25.60
Rate for Payer: MDX Hawaii PPO	$666.19
Rate for Payer: UnitedHealthcare Medicaid	$412.07
Rate for Payer: UnitedHealthcare Medicaid	$15.83
Rate for Payer: University Health Alliance Commercial	$19.24
Rate for Payer: University Health Alliance Commercial	$500.60

SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML PO SUSP

Facility

$686.79

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$583.77
Max. Negotiated Rate	$666.19
Rate for Payer: Cash Price	$446.41
Rate for Payer: Cash Price	$17.15
Rate for Payer: Health Management Network Commercial	$22.43
Rate for Payer: Health Management Network Commercial	$583.77
Rate for Payer: MDX Hawaii PPO	$666.19
Rate for Payer: MDX Hawaii PPO	$25.60

SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5 ML IV SOLN

Facility

$80.31

Service Code	HCPCS J2865
Hospital Revenue Code	250
Min. Negotiated Rate	$68.26
Max. Negotiated Rate	$77.90
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cash Price	$52.63
Rate for Payer: Health Management Network Commercial	$68.26
Rate for Payer: Health Management Network Commercial	$68.82
Rate for Payer: MDX Hawaii PPO	$77.90
Rate for Payer: MDX Hawaii PPO	$78.54

SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5 ML IV SOLN

Facility

$80.31

Service Code	HCPCS J2865
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$77.90
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cash Price	$52.63
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cash Price	$52.63
Rate for Payer: Hawaii Medical Service Association ABD	$0.05
Rate for Payer: Hawaii Medical Service Association ABD	$0.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.05
Rate for Payer: Hawaii Western Management Group Commercial	$76.92
Rate for Payer: Hawaii Western Management Group Commercial	$76.29
Rate for Payer: Health Management Network Commercial	$68.82
Rate for Payer: Health Management Network Commercial	$68.26
Rate for Payer: Kaiser Permanente Commercial	$51.01
Rate for Payer: Kaiser Permanente Commercial	$50.60
Rate for Payer: Kaiser Permanente Medicaid	$40.96
Rate for Payer: Kaiser Permanente Medicaid	$41.29
Rate for Payer: MDX Hawaii PPO	$77.90
Rate for Payer: MDX Hawaii PPO	$78.54
Rate for Payer: UnitedHealthcare Medicaid	$48.58
Rate for Payer: UnitedHealthcare Medicaid	$48.19
Rate for Payer: University Health Alliance Commercial	$58.54
Rate for Payer: University Health Alliance Commercial	$59.02

SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG PO TABLET

Facility

$3.68

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$3.57
Rate for Payer: Cash Price	$2.39
Rate for Payer: Health Management Network Commercial	$3.13
Rate for Payer: MDX Hawaii PPO	$3.57

SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG PO TABLET

Facility

$3.68

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.88
Max. Negotiated Rate	$3.57
Rate for Payer: Cash Price	$2.39
Rate for Payer: Hawaii Western Management Group Commercial	$3.50
Rate for Payer: Health Management Network Commercial	$3.13
Rate for Payer: Kaiser Permanente Commercial	$2.32
Rate for Payer: Kaiser Permanente Medicaid	$1.88
Rate for Payer: MDX Hawaii PPO	$3.57
Rate for Payer: UnitedHealthcare Medicaid	$2.21
Rate for Payer: University Health Alliance Commercial	$2.68

SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG PO TABLET

Facility

$1.75

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$1.14
Rate for Payer: Hawaii Western Management Group Commercial	$1.66
Rate for Payer: Health Management Network Commercial	$1.49
Rate for Payer: Kaiser Permanente Commercial	$1.10
Rate for Payer: Kaiser Permanente Medicaid	$0.89
Rate for Payer: MDX Hawaii PPO	$1.70
Rate for Payer: UnitedHealthcare Medicaid	$1.05
Rate for Payer: University Health Alliance Commercial	$1.28

SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG PO TABLET

Facility

$1.75

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$1.14
Rate for Payer: Health Management Network Commercial	$1.49
Rate for Payer: MDX Hawaii PPO	$1.70

SULFASALAZINE 500 MG PO TABLET

Facility

$1.42

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$1.38
Rate for Payer: Cash Price	$0.92
Rate for Payer: Health Management Network Commercial	$1.21
Rate for Payer: MDX Hawaii PPO	$1.38

SULFASALAZINE 500 MG PO TABLET

Facility

$1.42

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.38
Rate for Payer: Cash Price	$0.92
Rate for Payer: Hawaii Western Management Group Commercial	$1.35
Rate for Payer: Health Management Network Commercial	$1.21
Rate for Payer: Kaiser Permanente Commercial	$0.89
Rate for Payer: Kaiser Permanente Medicaid	$0.72
Rate for Payer: MDX Hawaii PPO	$1.38
Rate for Payer: UnitedHealthcare Medicaid	$0.85
Rate for Payer: University Health Alliance Commercial	$1.04

SUMATRIPTAN SUCCINATE 25 MG PO TABLET

Facility

$130.00

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$126.10
Rate for Payer: Cash Price	$84.50
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$110.50
Rate for Payer: Kaiser Permanente Commercial	$81.90
Rate for Payer: Kaiser Permanente Medicaid	$66.30
Rate for Payer: MDX Hawaii PPO	$126.10
Rate for Payer: UnitedHealthcare Medicaid	$78.00
Rate for Payer: University Health Alliance Commercial	$94.76

SUMATRIPTAN SUCCINATE 25 MG PO TABLET

Facility

$130.00

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$110.50
Max. Negotiated Rate	$126.10
Rate for Payer: Cash Price	$84.50
Rate for Payer: Health Management Network Commercial	$110.50
Rate for Payer: MDX Hawaii PPO	$126.10

SUMATRIPTAN SUCCINATE 50 MG PO TABLET

Facility

$122.08

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$62.26
Max. Negotiated Rate	$118.42
Rate for Payer: Cash Price	$79.35
Rate for Payer: Hawaii Western Management Group Commercial	$115.98
Rate for Payer: Health Management Network Commercial	$103.77
Rate for Payer: Kaiser Permanente Commercial	$76.91
Rate for Payer: Kaiser Permanente Medicaid	$62.26
Rate for Payer: MDX Hawaii PPO	$118.42
Rate for Payer: UnitedHealthcare Medicaid	$73.25
Rate for Payer: University Health Alliance Commercial	$88.98

SUMATRIPTAN SUCCINATE 50 MG PO TABLET

Facility

$122.08

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$103.77
Max. Negotiated Rate	$118.42
Rate for Payer: Cash Price	$79.35
Rate for Payer: Health Management Network Commercial	$103.77
Rate for Payer: MDX Hawaii PPO	$118.42

SUMATRIPTAN SUCCINATE 6 MG/0.5 ML SUBCUTANEOUS SOLN

Facility

$67.68

Service Code	HCPCS J3030
Hospital Revenue Code	636
Min. Negotiated Rate	$34.52
Max. Negotiated Rate	$79.64
Rate for Payer: Cash Price	$43.99
Rate for Payer: Cash Price	$43.99
Rate for Payer: Hawaii Medical Service Association ABD	$79.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$79.64
Rate for Payer: Hawaii Western Management Group Commercial	$64.30
Rate for Payer: Health Management Network Commercial	$57.53
Rate for Payer: Kaiser Permanente Commercial	$42.64
Rate for Payer: Kaiser Permanente Medicaid	$34.52
Rate for Payer: MDX Hawaii PPO	$65.65
Rate for Payer: UnitedHealthcare Medicaid	$40.61
Rate for Payer: University Health Alliance Commercial	$49.33

SUMATRIPTAN SUCCINATE 6 MG/0.5 ML SUBCUTANEOUS SOLN

Facility

$67.68

Service Code	HCPCS J3030
Hospital Revenue Code	250
Min. Negotiated Rate	$57.53
Max. Negotiated Rate	$65.65
Rate for Payer: Cash Price	$43.99
Rate for Payer: Health Management Network Commercial	$57.53
Rate for Payer: MDX Hawaii PPO	$65.65

SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC

Facility

$6,743.44

Service Code	CPT 46275
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$3,279.01
Rate for Payer: AlohaCare Medicare	$3,279.01
Rate for Payer: Devoted Health Medicare	$3,606.91
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,279.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$3,279.01
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,279.01
Rate for Payer: Ohana Health Plan Medicaid	$3,606.91
Rate for Payer: Ohana Health Plan Medicare	$3,279.01
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,279.01
Rate for Payer: University Health Alliance Commercial	$6,743.44

SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS

Facility

$6,743.44

Service Code	CPT 46270
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$3,279.01
Rate for Payer: AlohaCare Medicare	$3,279.01
Rate for Payer: Devoted Health Medicare	$3,606.91
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,279.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$3,279.01
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,279.01
Rate for Payer: Ohana Health Plan Medicaid	$3,606.91
Rate for Payer: Ohana Health Plan Medicare	$3,279.01
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,279.01
Rate for Payer: University Health Alliance Commercial	$6,743.44

SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED

Facility

$10,679.55

Service Code	CPT 46280
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$3,279.01
Rate for Payer: AlohaCare Medicare	$3,279.01
Rate for Payer: Devoted Health Medicare	$3,606.91
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,279.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$3,279.01
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,279.01
Rate for Payer: Ohana Health Plan Medicaid	$3,606.91
Rate for Payer: Ohana Health Plan Medicare	$3,279.01
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,279.01
Rate for Payer: University Health Alliance Commercial	$10,679.55

SURGICEL 0.5" X 2" 1955 [2702249]

Facility

$262.36

Hospital Charge Code	2702249
Hospital Revenue Code	272
Min. Negotiated Rate	$133.80
Max. Negotiated Rate	$254.49
Rate for Payer: Cash Price	$170.53
Rate for Payer: Hawaii Western Management Group Commercial	$249.24
Rate for Payer: Health Management Network Commercial	$223.01
Rate for Payer: Kaiser Permanente Commercial	$165.29
Rate for Payer: Kaiser Permanente Medicaid	$133.80
Rate for Payer: MDX Hawaii PPO	$254.49
Rate for Payer: University Health Alliance Commercial	$191.23

SURGICEL 0.5" X 2" 1955 [2702249]

Facility

$262.36

Hospital Charge Code	2702249
Hospital Revenue Code	272
Min. Negotiated Rate	$223.01
Max. Negotiated Rate	$254.49
Rate for Payer: Cash Price	$170.53
Rate for Payer: Health Management Network Commercial	$223.01
Rate for Payer: MDX Hawaii PPO	$254.49

SURGICEL 2" X 3" 1953 [2702250]

Facility

$454.99

Hospital Charge Code	2702250
Hospital Revenue Code	272
Min. Negotiated Rate	$232.04
Max. Negotiated Rate	$441.34
Rate for Payer: Cash Price	$295.74
Rate for Payer: Hawaii Western Management Group Commercial	$432.24
Rate for Payer: Health Management Network Commercial	$386.74
Rate for Payer: Kaiser Permanente Commercial	$286.64
Rate for Payer: Kaiser Permanente Medicaid	$232.04
Rate for Payer: MDX Hawaii PPO	$441.34
Rate for Payer: University Health Alliance Commercial	$331.64

Know your out-of-pocket cost for care.

All Charges