Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

G0463 Other Outpatient Visit New 2 Charges

Facility

$255.00

Service Code	HCPCS G0463
Hospital Charge Code	8221523
Hospital Revenue Code	761
Min. Negotiated Rate	$216.75
Max. Negotiated Rate	$247.35
Rate for Payer: Cash Price	$165.75
Rate for Payer: Health Management Network Commercial	$216.75
Rate for Payer: Kaiser Permanente Commercial	$229.50
Rate for Payer: MDX Hawaii PPO	$247.35

G0463 Other Outpatient Visit New 3 Charges

Facility

$293.00

Service Code	HCPCS G0463
Hospital Charge Code	8221524
Hospital Revenue Code	761
Min. Negotiated Rate	$249.05
Max. Negotiated Rate	$284.21
Rate for Payer: Cash Price	$190.45
Rate for Payer: Health Management Network Commercial	$249.05
Rate for Payer: Kaiser Permanente Commercial	$263.70
Rate for Payer: MDX Hawaii PPO	$284.21

G0463 Other Outpatient Visit New 3 Charges

Facility

$293.00

Service Code	HCPCS G0463
Hospital Charge Code	8221524
Hospital Revenue Code	761
Min. Negotiated Rate	$96.65
Max. Negotiated Rate	$284.21
Rate for Payer: AlohaCare Medicaid	$146.50
Rate for Payer: AlohaCare Medicare	$146.50
Rate for Payer: Cash Price	$190.45
Rate for Payer: Cash Price	$190.45
Rate for Payer: Devoted Health Medicare	$161.15
Rate for Payer: Hawaii Medical Service Association Commercial	$170.03
Rate for Payer: Hawaii Medical Service Association Medicare	$146.50
Rate for Payer: Hawaii Western Management Group Commercial	$278.35
Rate for Payer: Health Management Network Commercial	$249.05
Rate for Payer: Humana Medicare	$146.50
Rate for Payer: Kaiser Permanente Commercial	$263.70
Rate for Payer: Kaiser Permanente Medicaid	$149.43
Rate for Payer: Kaiser Permanente Medicare	$146.50
Rate for Payer: MDX Hawaii PPO	$284.21
Rate for Payer: Ohana Health Plan Medicaid	$146.50
Rate for Payer: Ohana Health Plan Medicare	$146.50
Rate for Payer: UnitedHealthcare Medicaid	$96.65
Rate for Payer: UnitedHealthcare Medicare	$146.50
Rate for Payer: University Health Alliance Commercial	$213.57

G0463 Other Outpatient Visit New 4 Charges

Facility

$428.00

Service Code	HCPCS G0463
Hospital Charge Code	8221525
Hospital Revenue Code	761
Min. Negotiated Rate	$96.65
Max. Negotiated Rate	$415.16
Rate for Payer: AlohaCare Medicaid	$214.00
Rate for Payer: AlohaCare Medicare	$214.00
Rate for Payer: Cash Price	$278.20
Rate for Payer: Cash Price	$278.20
Rate for Payer: Devoted Health Medicare	$235.40
Rate for Payer: Hawaii Medical Service Association Commercial	$170.03
Rate for Payer: Hawaii Medical Service Association Medicare	$214.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.60
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Humana Medicare	$214.00
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: Kaiser Permanente Medicaid	$218.28
Rate for Payer: Kaiser Permanente Medicare	$214.00
Rate for Payer: MDX Hawaii PPO	$415.16
Rate for Payer: Ohana Health Plan Medicaid	$214.00
Rate for Payer: Ohana Health Plan Medicare	$214.00
Rate for Payer: UnitedHealthcare Medicaid	$96.65
Rate for Payer: UnitedHealthcare Medicare	$214.00
Rate for Payer: University Health Alliance Commercial	$311.97

G0463 Other Outpatient Visit New 4 Charges

Facility

$428.00

Service Code	HCPCS G0463
Hospital Charge Code	8221525
Hospital Revenue Code	761
Min. Negotiated Rate	$363.80
Max. Negotiated Rate	$415.16
Rate for Payer: Cash Price	$278.20
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: MDX Hawaii PPO	$415.16

G0463 Other Outpatient Visit New 5 Charges

Facility

$428.00

Service Code	HCPCS G0463
Hospital Charge Code	8221526
Hospital Revenue Code	761
Min. Negotiated Rate	$363.80
Max. Negotiated Rate	$415.16
Rate for Payer: Cash Price	$278.20
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: MDX Hawaii PPO	$415.16

G0463 Other Outpatient Visit New 5 Charges

Facility

$428.00

Service Code	HCPCS G0463
Hospital Charge Code	8221526
Hospital Revenue Code	761
Min. Negotiated Rate	$96.65
Max. Negotiated Rate	$415.16
Rate for Payer: AlohaCare Medicaid	$214.00
Rate for Payer: AlohaCare Medicare	$214.00
Rate for Payer: Cash Price	$278.20
Rate for Payer: Cash Price	$278.20
Rate for Payer: Devoted Health Medicare	$235.40
Rate for Payer: Hawaii Medical Service Association Commercial	$170.03
Rate for Payer: Hawaii Medical Service Association Medicare	$214.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.60
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Humana Medicare	$214.00
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: Kaiser Permanente Medicaid	$218.28
Rate for Payer: Kaiser Permanente Medicare	$214.00
Rate for Payer: MDX Hawaii PPO	$415.16
Rate for Payer: Ohana Health Plan Medicaid	$214.00
Rate for Payer: Ohana Health Plan Medicare	$214.00
Rate for Payer: UnitedHealthcare Medicaid	$96.65
Rate for Payer: UnitedHealthcare Medicare	$214.00
Rate for Payer: University Health Alliance Commercial	$311.97

G0463 OUTPATIENT VISIT CHARGE

Facility

$479.00

Service Code	HCPCS G0463
Hospital Charge Code	8302170
Hospital Revenue Code	761
Min. Negotiated Rate	$96.65
Max. Negotiated Rate	$464.63
Rate for Payer: AlohaCare Medicaid	$239.50
Rate for Payer: AlohaCare Medicare	$239.50
Rate for Payer: Cash Price	$311.35
Rate for Payer: Cash Price	$311.35
Rate for Payer: Devoted Health Medicare	$263.45
Rate for Payer: Hawaii Medical Service Association Commercial	$170.03
Rate for Payer: Hawaii Medical Service Association Medicare	$239.50
Rate for Payer: Hawaii Western Management Group Commercial	$455.05
Rate for Payer: Health Management Network Commercial	$407.15
Rate for Payer: Humana Medicare	$239.50
Rate for Payer: Kaiser Permanente Commercial	$431.10
Rate for Payer: Kaiser Permanente Medicaid	$244.29
Rate for Payer: Kaiser Permanente Medicare	$239.50
Rate for Payer: MDX Hawaii PPO	$464.63
Rate for Payer: Ohana Health Plan Medicaid	$239.50
Rate for Payer: Ohana Health Plan Medicare	$239.50
Rate for Payer: UnitedHealthcare Medicaid	$96.65
Rate for Payer: UnitedHealthcare Medicare	$239.50
Rate for Payer: University Health Alliance Commercial	$349.14

G0463 OUTPATIENT VISIT CHARGE

Facility

$479.00

Service Code	HCPCS G0463
Hospital Charge Code	8302170
Hospital Revenue Code	761
Min. Negotiated Rate	$407.15
Max. Negotiated Rate	$464.63
Rate for Payer: Cash Price	$311.35
Rate for Payer: Health Management Network Commercial	$407.15
Rate for Payer: Kaiser Permanente Commercial	$431.10
Rate for Payer: MDX Hawaii PPO	$464.63

gabapentin 100 mg capsule [HHSC]

Facility

$3.00

Service Code	NDC 00904666561
Hospital Charge Code	2500348
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

gabapentin 100 mg capsule [HHSC]

Facility

$3.00

Service Code	NDC 00904666561
Hospital Charge Code	2500348
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 100 mg capsule [HHSC]

Facility

$3.00

Service Code	NDC 65162010110
Hospital Charge Code	2500348
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 100 mg capsule [HHSC]

Facility

$3.24

Service Code	NDC 68084078301
Hospital Charge Code	2500348
Hospital Revenue Code	250
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$3.14
Rate for Payer: AlohaCare Medicaid	$1.62
Rate for Payer: AlohaCare Medicare	$1.62
Rate for Payer: Cash Price	$2.11
Rate for Payer: Devoted Health Medicare	$1.78
Rate for Payer: Hawaii Medical Service Association Medicare	$1.62
Rate for Payer: Hawaii Western Management Group Commercial	$3.08
Rate for Payer: Health Management Network Commercial	$2.75
Rate for Payer: Humana Medicare	$1.62
Rate for Payer: Kaiser Permanente Commercial	$2.92
Rate for Payer: Kaiser Permanente Medicaid	$1.65
Rate for Payer: Kaiser Permanente Medicare	$1.62
Rate for Payer: MDX Hawaii PPO	$3.14
Rate for Payer: Ohana Health Plan Medicaid	$1.62
Rate for Payer: Ohana Health Plan Medicare	$1.62
Rate for Payer: UnitedHealthcare Medicaid	$1.94
Rate for Payer: UnitedHealthcare Medicare	$1.62
Rate for Payer: University Health Alliance Commercial	$2.36

gabapentin 100 mg capsule [HHSC]

Facility

$3.24

Service Code	NDC 68084078301
Hospital Charge Code	2500348
Hospital Revenue Code	250
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$3.14
Rate for Payer: Cash Price	$2.11
Rate for Payer: Health Management Network Commercial	$2.75
Rate for Payer: Kaiser Permanente Commercial	$2.92
Rate for Payer: MDX Hawaii PPO	$3.14

gabapentin 100 mg capsule [HHSC]

Facility

$3.00

Service Code	NDC 65162010110
Hospital Charge Code	2500348
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

gabapentin 100 mg capsule [HHSC]

Facility

$3.24

Service Code	NDC 60687058001
Hospital Charge Code	2500348
Hospital Revenue Code	250
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$3.14
Rate for Payer: AlohaCare Medicaid	$1.62
Rate for Payer: AlohaCare Medicare	$1.62
Rate for Payer: Cash Price	$2.11
Rate for Payer: Devoted Health Medicare	$1.78
Rate for Payer: Hawaii Medical Service Association Medicare	$1.62
Rate for Payer: Hawaii Western Management Group Commercial	$3.08
Rate for Payer: Health Management Network Commercial	$2.75
Rate for Payer: Humana Medicare	$1.62
Rate for Payer: Kaiser Permanente Commercial	$2.92
Rate for Payer: Kaiser Permanente Medicaid	$1.65
Rate for Payer: Kaiser Permanente Medicare	$1.62
Rate for Payer: MDX Hawaii PPO	$3.14
Rate for Payer: Ohana Health Plan Medicaid	$1.62
Rate for Payer: Ohana Health Plan Medicare	$1.62
Rate for Payer: UnitedHealthcare Medicaid	$1.94
Rate for Payer: UnitedHealthcare Medicare	$1.62
Rate for Payer: University Health Alliance Commercial	$2.36

gabapentin 100 mg capsule [HHSC]

Facility

$3.24

Service Code	NDC 60687058001
Hospital Charge Code	2500348
Hospital Revenue Code	250
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$3.14
Rate for Payer: Cash Price	$2.11
Rate for Payer: Health Management Network Commercial	$2.75
Rate for Payer: Kaiser Permanente Commercial	$2.92
Rate for Payer: MDX Hawaii PPO	$3.14

gabapentin 300 mg capsule [HHSC]

Facility

$7.46

Service Code	NDC 65162010210
Hospital Charge Code	2500349
Hospital Revenue Code	250
Min. Negotiated Rate	$3.73
Max. Negotiated Rate	$7.24
Rate for Payer: AlohaCare Medicaid	$3.73
Rate for Payer: AlohaCare Medicare	$3.73
Rate for Payer: Cash Price	$4.85
Rate for Payer: Devoted Health Medicare	$4.10
Rate for Payer: Hawaii Medical Service Association Medicare	$3.73
Rate for Payer: Hawaii Western Management Group Commercial	$7.09
Rate for Payer: Health Management Network Commercial	$6.34
Rate for Payer: Humana Medicare	$3.73
Rate for Payer: Kaiser Permanente Commercial	$6.71
Rate for Payer: Kaiser Permanente Medicaid	$3.80
Rate for Payer: Kaiser Permanente Medicare	$3.73
Rate for Payer: MDX Hawaii PPO	$7.24
Rate for Payer: Ohana Health Plan Medicaid	$3.73
Rate for Payer: Ohana Health Plan Medicare	$3.73
Rate for Payer: UnitedHealthcare Medicaid	$4.48
Rate for Payer: UnitedHealthcare Medicare	$3.73
Rate for Payer: University Health Alliance Commercial	$5.44

gabapentin 300 mg capsule [HHSC]

Facility

$3.00

Service Code	NDC 00904666661
Hospital Charge Code	2500349
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

gabapentin 300 mg capsule [HHSC]

Facility

$7.65

Service Code	NDC 68084076201
Hospital Charge Code	2500349
Hospital Revenue Code	250
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$7.42
Rate for Payer: AlohaCare Medicaid	$3.83
Rate for Payer: AlohaCare Medicare	$3.83
Rate for Payer: Cash Price	$4.97
Rate for Payer: Devoted Health Medicare	$4.21
Rate for Payer: Hawaii Medical Service Association Medicare	$3.83
Rate for Payer: Hawaii Western Management Group Commercial	$7.27
Rate for Payer: Health Management Network Commercial	$6.50
Rate for Payer: Humana Medicare	$3.83
Rate for Payer: Kaiser Permanente Commercial	$6.88
Rate for Payer: Kaiser Permanente Medicaid	$3.90
Rate for Payer: Kaiser Permanente Medicare	$3.83
Rate for Payer: MDX Hawaii PPO	$7.42
Rate for Payer: Ohana Health Plan Medicaid	$3.83
Rate for Payer: Ohana Health Plan Medicare	$3.83
Rate for Payer: UnitedHealthcare Medicaid	$4.59
Rate for Payer: UnitedHealthcare Medicare	$3.83
Rate for Payer: University Health Alliance Commercial	$5.58

gabapentin 300 mg capsule [HHSC]

Facility

$7.46

Service Code	NDC 65162010210
Hospital Charge Code	2500349
Hospital Revenue Code	250
Min. Negotiated Rate	$6.34
Max. Negotiated Rate	$7.24
Rate for Payer: Cash Price	$4.85
Rate for Payer: Health Management Network Commercial	$6.34
Rate for Payer: Kaiser Permanente Commercial	$6.71
Rate for Payer: MDX Hawaii PPO	$7.24

gabapentin 300 mg capsule [HHSC]

Facility

$7.65

Service Code	NDC 60687059101
Hospital Charge Code	2500349
Hospital Revenue Code	250
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$7.42
Rate for Payer: Cash Price	$4.97
Rate for Payer: Health Management Network Commercial	$6.50
Rate for Payer: Kaiser Permanente Commercial	$6.88
Rate for Payer: MDX Hawaii PPO	$7.42

gabapentin 300 mg capsule [HHSC]

Facility

$7.65

Service Code	NDC 60687059101
Hospital Charge Code	2500349
Hospital Revenue Code	250
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$7.42
Rate for Payer: AlohaCare Medicaid	$3.83
Rate for Payer: AlohaCare Medicare	$3.83
Rate for Payer: Cash Price	$4.97
Rate for Payer: Devoted Health Medicare	$4.21
Rate for Payer: Hawaii Medical Service Association Medicare	$3.83
Rate for Payer: Hawaii Western Management Group Commercial	$7.27
Rate for Payer: Health Management Network Commercial	$6.50
Rate for Payer: Humana Medicare	$3.83
Rate for Payer: Kaiser Permanente Commercial	$6.88
Rate for Payer: Kaiser Permanente Medicaid	$3.90
Rate for Payer: Kaiser Permanente Medicare	$3.83
Rate for Payer: MDX Hawaii PPO	$7.42
Rate for Payer: Ohana Health Plan Medicaid	$3.83
Rate for Payer: Ohana Health Plan Medicare	$3.83
Rate for Payer: UnitedHealthcare Medicaid	$4.59
Rate for Payer: UnitedHealthcare Medicare	$3.83
Rate for Payer: University Health Alliance Commercial	$5.58

gabapentin 300 mg capsule [HHSC]

Facility

$3.00

Service Code	NDC 00904666661
Hospital Charge Code	2500349
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 300 mg capsule [HHSC]

Facility

$7.65

Service Code	NDC 68084076201
Hospital Charge Code	2500349
Hospital Revenue Code	250
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$7.42
Rate for Payer: Cash Price	$4.97
Rate for Payer: Health Management Network Commercial	$6.50
Rate for Payer: Kaiser Permanente Commercial	$6.88
Rate for Payer: MDX Hawaii PPO	$7.42

Know your out-of-pocket cost for care.

All Charges