Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

gabapentin 100 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 63739090210
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

gabapentin 200 mg/4 mL Soln [KMC]

Facility

$1.26

Service Code	NDC 65162069890
Hospital Revenue Code	250
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$1.22
Rate for Payer: Cash Price	$0.82
Rate for Payer: Health Management Network Commercial	$1.07
Rate for Payer: Kaiser Permanente Commercial	$1.13
Rate for Payer: MDX Hawaii PPO	$1.22

gabapentin 200 mg/4 mL Soln [KMC]

Facility

$1.26

Service Code	NDC 65162069890
Hospital Revenue Code	250
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$1.22
Rate for Payer: AlohaCare Medicaid	$0.63
Rate for Payer: AlohaCare Medicare	$0.53
Rate for Payer: Cash Price	$0.82
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.16
Rate for Payer: Devoted Health Medicare	$0.53
Rate for Payer: Hawaii Medical Service Association Medicare	$0.53
Rate for Payer: Hawaii Western Management Group Commercial	$1.20
Rate for Payer: Health Management Network Commercial	$1.07
Rate for Payer: Humana Medicare	$0.53
Rate for Payer: Kaiser Permanente Commercial	$1.13
Rate for Payer: Kaiser Permanente Medicaid	$0.64
Rate for Payer: Kaiser Permanente Medicare	$0.53
Rate for Payer: MDX Hawaii PPO	$1.22
Rate for Payer: Ohana Health Plan Medicaid	$0.53
Rate for Payer: Ohana Health Plan Medicare	$0.53
Rate for Payer: UnitedHealthcare Medicaid	$0.76
Rate for Payer: UnitedHealthcare Medicare	$0.53
Rate for Payer: University Health Alliance Commercial	$0.92

gabapentin 300 mg Cap [KMC]

Facility

$5.51

Service Code	NDC 60687059101
Hospital Revenue Code	250
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$5.34
Rate for Payer: AlohaCare Medicaid	$2.75
Rate for Payer: AlohaCare Medicare	$2.31
Rate for Payer: Cash Price	$3.58
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.07
Rate for Payer: Devoted Health Medicare	$2.31
Rate for Payer: Hawaii Medical Service Association Medicare	$2.31
Rate for Payer: Hawaii Western Management Group Commercial	$5.23
Rate for Payer: Health Management Network Commercial	$4.68
Rate for Payer: Humana Medicare	$2.31
Rate for Payer: Kaiser Permanente Commercial	$4.96
Rate for Payer: Kaiser Permanente Medicaid	$2.81
Rate for Payer: Kaiser Permanente Medicare	$2.31
Rate for Payer: MDX Hawaii PPO	$5.34
Rate for Payer: Ohana Health Plan Medicaid	$2.31
Rate for Payer: Ohana Health Plan Medicare	$2.31
Rate for Payer: UnitedHealthcare Medicaid	$3.31
Rate for Payer: UnitedHealthcare Medicare	$2.31
Rate for Payer: University Health Alliance Commercial	$4.02

gabapentin 300 mg Cap [KMC]

Facility

$5.51

Service Code	NDC 60687059101
Hospital Revenue Code	250
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$5.34
Rate for Payer: Cash Price	$3.58
Rate for Payer: Health Management Network Commercial	$4.68
Rate for Payer: Kaiser Permanente Commercial	$4.96
Rate for Payer: MDX Hawaii PPO	$5.34

gabapentin 400 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 63739090410
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

gabapentin 400 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 63739090410
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

gabapentin 600 mg Tab [KMC]

Facility

$10.10

Service Code	NDC 16714033001
Hospital Revenue Code	250
Min. Negotiated Rate	$4.24
Max. Negotiated Rate	$9.80
Rate for Payer: AlohaCare Medicaid	$5.05
Rate for Payer: AlohaCare Medicare	$4.24
Rate for Payer: Cash Price	$6.56
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9.29
Rate for Payer: Devoted Health Medicare	$4.24
Rate for Payer: Hawaii Medical Service Association Medicare	$4.24
Rate for Payer: Hawaii Western Management Group Commercial	$9.60
Rate for Payer: Health Management Network Commercial	$8.59
Rate for Payer: Humana Medicare	$4.24
Rate for Payer: Kaiser Permanente Commercial	$9.09
Rate for Payer: Kaiser Permanente Medicaid	$5.15
Rate for Payer: Kaiser Permanente Medicare	$4.24
Rate for Payer: MDX Hawaii PPO	$9.80
Rate for Payer: Ohana Health Plan Medicaid	$4.24
Rate for Payer: Ohana Health Plan Medicare	$4.24
Rate for Payer: UnitedHealthcare Medicaid	$6.06
Rate for Payer: UnitedHealthcare Medicare	$4.24
Rate for Payer: University Health Alliance Commercial	$7.36

gabapentin 600 mg Tab [KMC]

Facility

$10.10

Service Code	NDC 16714033001
Hospital Revenue Code	250
Min. Negotiated Rate	$8.59
Max. Negotiated Rate	$9.80
Rate for Payer: Cash Price	$6.56
Rate for Payer: Health Management Network Commercial	$8.59
Rate for Payer: Kaiser Permanente Commercial	$9.09
Rate for Payer: MDX Hawaii PPO	$9.80

gabapentin 800 mg Tab [KMC]

Facility

$12.13

Service Code	NDC 16714033201
Hospital Revenue Code	250
Min. Negotiated Rate	$5.09
Max. Negotiated Rate	$11.77
Rate for Payer: AlohaCare Medicaid	$6.07
Rate for Payer: AlohaCare Medicare	$5.09
Rate for Payer: Cash Price	$7.88
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$11.16
Rate for Payer: Devoted Health Medicare	$5.09
Rate for Payer: Hawaii Medical Service Association Medicare	$5.09
Rate for Payer: Hawaii Western Management Group Commercial	$11.52
Rate for Payer: Health Management Network Commercial	$10.31
Rate for Payer: Humana Medicare	$5.09
Rate for Payer: Kaiser Permanente Commercial	$10.92
Rate for Payer: Kaiser Permanente Medicaid	$6.19
Rate for Payer: Kaiser Permanente Medicare	$5.09
Rate for Payer: MDX Hawaii PPO	$11.77
Rate for Payer: Ohana Health Plan Medicaid	$5.09
Rate for Payer: Ohana Health Plan Medicare	$5.09
Rate for Payer: UnitedHealthcare Medicaid	$7.28
Rate for Payer: UnitedHealthcare Medicare	$5.09
Rate for Payer: University Health Alliance Commercial	$8.84

gabapentin 800 mg Tab [KMC]

Facility

$12.13

Service Code	NDC 16714033201
Hospital Revenue Code	250
Min. Negotiated Rate	$10.31
Max. Negotiated Rate	$11.77
Rate for Payer: Cash Price	$7.88
Rate for Payer: Health Management Network Commercial	$10.31
Rate for Payer: Kaiser Permanente Commercial	$10.92
Rate for Payer: MDX Hawaii PPO	$11.77

GAIT TRAIN EACH 15 MIN Occupational

Facility

$153.00

Service Code	HCPCS 97116 GO
Hospital Charge Code	432971160
Hospital Revenue Code	430
Min. Negotiated Rate	$16.70
Max. Negotiated Rate	$148.41
Rate for Payer: AlohaCare Medicaid	$76.50
Rate for Payer: AlohaCare Medicare	$64.26
Rate for Payer: Cash Price	$99.45
Rate for Payer: Cash Price	$99.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$140.76
Rate for Payer: Devoted Health Medicare	$64.26
Rate for Payer: Hawaii Medical Service Association Medicare	$64.26
Rate for Payer: Hawaii Western Management Group Commercial	$145.35
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Humana Medicare	$64.26
Rate for Payer: Kaiser Permanente Commercial	$137.70
Rate for Payer: Kaiser Permanente Medicaid	$78.03
Rate for Payer: Kaiser Permanente Medicare	$64.26
Rate for Payer: MDX Hawaii PPO	$148.41
Rate for Payer: Ohana Health Plan Medicaid	$64.26
Rate for Payer: Ohana Health Plan Medicare	$64.26
Rate for Payer: UnitedHealthcare Medicaid	$16.70
Rate for Payer: UnitedHealthcare Medicare	$64.26
Rate for Payer: University Health Alliance Commercial	$111.52

GAIT TRAIN EACH 15 MIN Occupational

Facility

$153.00

Service Code	HCPCS 97116 GO
Hospital Charge Code	432971160
Hospital Revenue Code	430
Min. Negotiated Rate	$130.05
Max. Negotiated Rate	$148.41
Rate for Payer: Cash Price	$99.45
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Kaiser Permanente Commercial	$137.70
Rate for Payer: MDX Hawaii PPO	$148.41

GAIT TRAIN EACH 15 MIN Physical

Facility

$179.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	426971160
Hospital Revenue Code	420
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

GAIT TRAIN EACH 15 MIN Physical

Facility

$179.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	426971160
Hospital Revenue Code	420
Min. Negotiated Rate	$16.70
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$75.18
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$164.68
Rate for Payer: Devoted Health Medicare	$75.18
Rate for Payer: Hawaii Medical Service Association Medicare	$75.18
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$75.18
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$75.18
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$75.18
Rate for Payer: Ohana Health Plan Medicare	$75.18
Rate for Payer: UnitedHealthcare Medicaid	$16.70
Rate for Payer: UnitedHealthcare Medicare	$75.18
Rate for Payer: University Health Alliance Commercial	$130.47

galcanezumab 120 mg/mL Soln [KMC]

Facility

$2,897.28

Service Code	NDC 00002237711
Hospital Revenue Code	250
Min. Negotiated Rate	$2,462.69
Max. Negotiated Rate	$2,810.36
Rate for Payer: Cash Price	$1,883.23
Rate for Payer: Health Management Network Commercial	$2,462.69
Rate for Payer: Kaiser Permanente Commercial	$2,607.55
Rate for Payer: MDX Hawaii PPO	$2,810.36

galcanezumab 120 mg/mL Soln [KMC]

Facility

$2,897.28

Service Code	NDC 00002237711
Hospital Revenue Code	250
Min. Negotiated Rate	$1,216.86
Max. Negotiated Rate	$2,810.36
Rate for Payer: AlohaCare Medicaid	$1,448.64
Rate for Payer: AlohaCare Medicare	$1,216.86
Rate for Payer: Cash Price	$1,883.23
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2,665.50
Rate for Payer: Devoted Health Medicare	$1,216.86
Rate for Payer: Hawaii Medical Service Association Medicare	$1,216.86
Rate for Payer: Hawaii Western Management Group Commercial	$2,752.42
Rate for Payer: Health Management Network Commercial	$2,462.69
Rate for Payer: Humana Medicare	$1,216.86
Rate for Payer: Kaiser Permanente Commercial	$2,607.55
Rate for Payer: Kaiser Permanente Medicaid	$1,477.61
Rate for Payer: Kaiser Permanente Medicare	$1,216.86
Rate for Payer: MDX Hawaii PPO	$2,810.36
Rate for Payer: Ohana Health Plan Medicaid	$1,216.86
Rate for Payer: Ohana Health Plan Medicare	$1,216.86
Rate for Payer: UnitedHealthcare Medicaid	$1,738.37
Rate for Payer: UnitedHealthcare Medicare	$1,216.86
Rate for Payer: University Health Alliance Commercial	$2,111.83

Gamma GT DLS

Facility

$96.00

Service Code	HCPCS 82977
Hospital Charge Code	422829775
Hospital Revenue Code	301
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$62.40
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: MDX Hawaii PPO	$93.12

Gamma GT DLS

Facility

$96.00

Service Code	HCPCS 82977
Hospital Charge Code	422829775
Hospital Revenue Code	301
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$93.12
Rate for Payer: AlohaCare Medicaid	$48.00
Rate for Payer: AlohaCare Medicare	$40.32
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$62.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$88.32
Rate for Payer: Devoted Health Medicare	$40.32
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$9.95
Rate for Payer: Hawaii Medical Service Association Commercial	$9.00
Rate for Payer: Hawaii Medical Service Association Medicare	$40.32
Rate for Payer: Hawaii Western Management Group Commercial	$7.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Humana Medicare	$40.32
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: Kaiser Permanente Medicaid	$48.96
Rate for Payer: Kaiser Permanente Medicare	$40.32
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: Ohana Health Plan Medicaid	$40.32
Rate for Payer: Ohana Health Plan Medicare	$40.32
Rate for Payer: UnitedHealthcare Medicaid	$9.95
Rate for Payer: UnitedHealthcare Medicare	$40.32
Rate for Payer: University Health Alliance Commercial	$18.61

Gastric Occult Blood

Facility

$45.00

Service Code	HCPCS 82271
Hospital Charge Code	422822710
Hospital Revenue Code	305
Min. Negotiated Rate	$4.54
Max. Negotiated Rate	$43.65
Rate for Payer: AlohaCare Medicaid	$22.50
Rate for Payer: AlohaCare Medicare	$18.90
Rate for Payer: Cash Price	$29.25
Rate for Payer: Cash Price	$29.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$41.40
Rate for Payer: Devoted Health Medicare	$18.90
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$4.54
Rate for Payer: Hawaii Medical Service Association Commercial	$6.65
Rate for Payer: Hawaii Medical Service Association Medicare	$18.90
Rate for Payer: Hawaii Western Management Group Commercial	$5.32
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Humana Medicare	$18.90
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: Kaiser Permanente Medicaid	$22.95
Rate for Payer: Kaiser Permanente Medicare	$18.90
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: Ohana Health Plan Medicaid	$18.90
Rate for Payer: Ohana Health Plan Medicare	$18.90
Rate for Payer: UnitedHealthcare Medicaid	$4.54
Rate for Payer: UnitedHealthcare Medicare	$18.90
Rate for Payer: University Health Alliance Commercial	$8.40

Gastric Occult Blood

Facility

$45.00

Service Code	HCPCS 82271
Hospital Charge Code	422822710
Hospital Revenue Code	305
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$29.25
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: MDX Hawaii PPO	$43.65

Gastrointestinal endoscopic ultrasound, supervision and interpretation

Facility

$185.00

Service Code	HCPCS 76975
Hospital Charge Code	424769759
Hospital Revenue Code	972
Min. Negotiated Rate	$157.25
Max. Negotiated Rate	$179.45
Rate for Payer: Cash Price	$120.25
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Health Management Network Commercial	$149.60
Rate for Payer: Kaiser Permanente Commercial	$166.50
Rate for Payer: Kaiser Permanente Commercial	$158.40
Rate for Payer: MDX Hawaii PPO	$179.45
Rate for Payer: MDX Hawaii PPO	$170.72

Gastrointestinal endoscopic ultrasound, supervision and interpretation

Facility

$185.00

Service Code	HCPCS 76975
Hospital Charge Code	424769759
Hospital Revenue Code	972
Min. Negotiated Rate	$50.35
Max. Negotiated Rate	$352.34
Rate for Payer: AlohaCare Medicaid	$92.50
Rate for Payer: AlohaCare Medicaid	$88.00
Rate for Payer: AlohaCare Medicare	$73.92
Rate for Payer: AlohaCare Medicare	$77.70
Rate for Payer: Cash Price	$120.25
Rate for Payer: Cash Price	$114.40
Rate for Payer: Cash Price	$114.40
Rate for Payer: Cash Price	$120.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$161.92
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$170.20
Rate for Payer: Devoted Health Medicare	$77.70
Rate for Payer: Devoted Health Medicare	$73.92
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$50.35
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$50.35
Rate for Payer: Hawaii Medical Service Association Commercial	$352.34
Rate for Payer: Hawaii Medical Service Association Commercial	$352.34
Rate for Payer: Hawaii Medical Service Association Medicare	$73.92
Rate for Payer: Hawaii Medical Service Association Medicare	$77.70
Rate for Payer: Hawaii Western Management Group Commercial	$281.87
Rate for Payer: Hawaii Western Management Group Commercial	$281.87
Rate for Payer: Health Management Network Commercial	$149.60
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Humana Medicare	$77.70
Rate for Payer: Humana Medicare	$73.92
Rate for Payer: Kaiser Permanente Commercial	$158.40
Rate for Payer: Kaiser Permanente Commercial	$166.50
Rate for Payer: Kaiser Permanente Medicaid	$94.35
Rate for Payer: Kaiser Permanente Medicaid	$89.76
Rate for Payer: Kaiser Permanente Medicare	$77.70
Rate for Payer: Kaiser Permanente Medicare	$73.92
Rate for Payer: MDX Hawaii PPO	$179.45
Rate for Payer: MDX Hawaii PPO	$170.72
Rate for Payer: Ohana Health Plan Medicaid	$77.70
Rate for Payer: Ohana Health Plan Medicaid	$73.92
Rate for Payer: Ohana Health Plan Medicare	$77.70
Rate for Payer: Ohana Health Plan Medicare	$73.92
Rate for Payer: UnitedHealthcare Medicaid	$50.35
Rate for Payer: UnitedHealthcare Medicaid	$50.35
Rate for Payer: UnitedHealthcare Medicare	$77.70
Rate for Payer: UnitedHealthcare Medicare	$73.92
Rate for Payer: University Health Alliance Commercial	$128.29
Rate for Payer: University Health Alliance Commercial	$134.85

GASTROINTESTINAL HEMORRHAGE WITH CC

Facility

$21,355.50

Service Code	MSDRG 378
Min. Negotiated Rate	$21,355.50
Max. Negotiated Rate	$21,355.50
Rate for Payer: Hawaii Medical Service Association Commercial	$21,355.50

GASTROINTESTINAL HEMORRHAGE WITH MCC

Facility

$21,355.50

Service Code	MSDRG 377
Min. Negotiated Rate	$21,355.50
Max. Negotiated Rate	$21,355.50
Rate for Payer: Hawaii Medical Service Association Commercial	$21,355.50

Know your out-of-pocket cost for care.

All Charges