Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

gabapentin 600 mg tablet [HHSC]

Facility

$13.47

Service Code	NDC 60687050701
Hospital Charge Code	2500350
Hospital Revenue Code	250
Min. Negotiated Rate	$6.74
Max. Negotiated Rate	$13.07
Rate for Payer: AlohaCare Medicaid	$6.74
Rate for Payer: AlohaCare Medicare	$6.74
Rate for Payer: Cash Price	$8.76
Rate for Payer: Devoted Health Medicare	$7.41
Rate for Payer: Hawaii Medical Service Association Medicare	$6.74
Rate for Payer: Hawaii Western Management Group Commercial	$12.80
Rate for Payer: Health Management Network Commercial	$11.45
Rate for Payer: Humana Medicare	$6.74
Rate for Payer: Kaiser Permanente Commercial	$12.12
Rate for Payer: Kaiser Permanente Medicaid	$6.87
Rate for Payer: Kaiser Permanente Medicare	$6.74
Rate for Payer: MDX Hawaii PPO	$13.07
Rate for Payer: Ohana Health Plan Medicaid	$6.74
Rate for Payer: Ohana Health Plan Medicare	$6.74
Rate for Payer: UnitedHealthcare Medicaid	$8.08
Rate for Payer: UnitedHealthcare Medicare	$6.74
Rate for Payer: University Health Alliance Commercial	$9.82

gabapentin 600 mg tablet [HHSC]

Facility

$13.47

Service Code	NDC 60687050701
Hospital Charge Code	2500350
Hospital Revenue Code	250
Min. Negotiated Rate	$11.45
Max. Negotiated Rate	$13.07
Rate for Payer: Cash Price	$8.76
Rate for Payer: Health Management Network Commercial	$11.45
Rate for Payer: Kaiser Permanente Commercial	$12.12
Rate for Payer: MDX Hawaii PPO	$13.07

gabapentin 600 mg tablet [HHSC]

Facility

$13.47

Service Code	NDC 68084079701
Hospital Charge Code	2500350
Hospital Revenue Code	250
Min. Negotiated Rate	$6.74
Max. Negotiated Rate	$13.07
Rate for Payer: AlohaCare Medicaid	$6.74
Rate for Payer: AlohaCare Medicare	$6.74
Rate for Payer: Cash Price	$8.76
Rate for Payer: Devoted Health Medicare	$7.41
Rate for Payer: Hawaii Medical Service Association Medicare	$6.74
Rate for Payer: Hawaii Western Management Group Commercial	$12.80
Rate for Payer: Health Management Network Commercial	$11.45
Rate for Payer: Humana Medicare	$6.74
Rate for Payer: Kaiser Permanente Commercial	$12.12
Rate for Payer: Kaiser Permanente Medicaid	$6.87
Rate for Payer: Kaiser Permanente Medicare	$6.74
Rate for Payer: MDX Hawaii PPO	$13.07
Rate for Payer: Ohana Health Plan Medicaid	$6.74
Rate for Payer: Ohana Health Plan Medicare	$6.74
Rate for Payer: UnitedHealthcare Medicaid	$8.08
Rate for Payer: UnitedHealthcare Medicare	$6.74
Rate for Payer: University Health Alliance Commercial	$9.82

gabapentin 600 mg tablet [HHSC]

Facility

$13.47

Service Code	NDC 68084079701
Hospital Charge Code	2500350
Hospital Revenue Code	250
Min. Negotiated Rate	$11.45
Max. Negotiated Rate	$13.07
Rate for Payer: Cash Price	$8.76
Rate for Payer: Health Management Network Commercial	$11.45
Rate for Payer: Kaiser Permanente Commercial	$12.12
Rate for Payer: MDX Hawaii PPO	$13.07

gadoteridol 279.3 mg/mL 5 mL vial [HHSC]

Facility

$166.86

Service Code	HCPCS A9576
Hospital Charge Code	2500885
Hospital Revenue Code	250
Min. Negotiated Rate	$141.83
Max. Negotiated Rate	$161.85
Rate for Payer: Cash Price	$108.46
Rate for Payer: Health Management Network Commercial	$141.83
Rate for Payer: Kaiser Permanente Commercial	$150.17
Rate for Payer: MDX Hawaii PPO	$161.85

gadoteridol 279.3 mg/mL 5 mL vial [HHSC]

Facility

$166.86

Service Code	HCPCS A9576
Hospital Charge Code	2500885
Hospital Revenue Code	636
Min. Negotiated Rate	$83.43
Max. Negotiated Rate	$161.85
Rate for Payer: AlohaCare Medicaid	$83.43
Rate for Payer: AlohaCare Medicare	$83.43
Rate for Payer: Cash Price	$108.46
Rate for Payer: Devoted Health Medicare	$91.77
Rate for Payer: Hawaii Medical Service Association Medicare	$83.43
Rate for Payer: Hawaii Western Management Group Commercial	$158.52
Rate for Payer: Health Management Network Commercial	$141.83
Rate for Payer: Humana Medicare	$83.43
Rate for Payer: Kaiser Permanente Commercial	$150.17
Rate for Payer: Kaiser Permanente Medicaid	$85.10
Rate for Payer: Kaiser Permanente Medicare	$83.43
Rate for Payer: MDX Hawaii PPO	$161.85
Rate for Payer: Ohana Health Plan Medicaid	$83.43
Rate for Payer: Ohana Health Plan Medicare	$83.43
Rate for Payer: UnitedHealthcare Medicaid	$100.12
Rate for Payer: UnitedHealthcare Medicare	$83.43
Rate for Payer: University Health Alliance Commercial	$121.62

gadoversetamide 0.5 mmol/mL injection [HHSC]

Facility

$104.22

Service Code	HCPCS A9579
Hospital Charge Code	2500901
Hospital Revenue Code	636
Min. Negotiated Rate	$52.11
Max. Negotiated Rate	$101.09
Rate for Payer: AlohaCare Medicaid	$52.11
Rate for Payer: AlohaCare Medicare	$52.11
Rate for Payer: Cash Price	$67.74
Rate for Payer: Devoted Health Medicare	$57.32
Rate for Payer: Hawaii Medical Service Association Medicare	$52.11
Rate for Payer: Hawaii Western Management Group Commercial	$99.01
Rate for Payer: Health Management Network Commercial	$88.59
Rate for Payer: Humana Medicare	$52.11
Rate for Payer: Kaiser Permanente Commercial	$93.80
Rate for Payer: Kaiser Permanente Medicaid	$53.15
Rate for Payer: Kaiser Permanente Medicare	$52.11
Rate for Payer: MDX Hawaii PPO	$101.09
Rate for Payer: Ohana Health Plan Medicaid	$52.11
Rate for Payer: Ohana Health Plan Medicare	$52.11
Rate for Payer: UnitedHealthcare Medicaid	$62.53
Rate for Payer: UnitedHealthcare Medicare	$52.11
Rate for Payer: University Health Alliance Commercial	$75.97

gadoversetamide 0.5 mmol/mL injection [HHSC]

Facility

$104.22

Service Code	HCPCS A9579
Hospital Charge Code	2500901
Hospital Revenue Code	250
Min. Negotiated Rate	$88.59
Max. Negotiated Rate	$101.09
Rate for Payer: Cash Price	$67.74
Rate for Payer: Health Management Network Commercial	$88.59
Rate for Payer: Kaiser Permanente Commercial	$93.80
Rate for Payer: MDX Hawaii PPO	$101.09

Gait Training Charges

Facility

$238.00

Service Code	HCPCS 97116 GP,CQ
Hospital Charge Code	8111691
Hospital Revenue Code	420
Min. Negotiated Rate	$16.70
Max. Negotiated Rate	$230.86
Rate for Payer: AlohaCare Medicaid	$119.00
Rate for Payer: AlohaCare Medicare	$119.00
Rate for Payer: Cash Price	$154.70
Rate for Payer: Cash Price	$154.70
Rate for Payer: Devoted Health Medicare	$130.90
Rate for Payer: Hawaii Medical Service Association Medicare	$119.00
Rate for Payer: Hawaii Western Management Group Commercial	$226.10
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Humana Medicare	$119.00
Rate for Payer: Kaiser Permanente Commercial	$214.20
Rate for Payer: Kaiser Permanente Medicaid	$121.38
Rate for Payer: Kaiser Permanente Medicare	$119.00
Rate for Payer: MDX Hawaii PPO	$230.86
Rate for Payer: Ohana Health Plan Medicaid	$119.00
Rate for Payer: Ohana Health Plan Medicare	$119.00
Rate for Payer: UnitedHealthcare Medicaid	$16.70
Rate for Payer: UnitedHealthcare Medicare	$119.00
Rate for Payer: University Health Alliance Commercial	$173.48

Gait Training Charges

Facility

$238.00

Service Code	HCPCS 97116 GP,CQ
Hospital Charge Code	8111691
Hospital Revenue Code	420
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$230.86
Rate for Payer: Cash Price	$154.70
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Kaiser Permanente Commercial	$214.20
Rate for Payer: MDX Hawaii PPO	$230.86

Gastric Intubation and Aspiraton Therapeutic

Facility

$544.00

Service Code	HCPCS 43753
Hospital Charge Code	12647404
Hospital Revenue Code	361
Min. Negotiated Rate	$12.77
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$272.00
Rate for Payer: AlohaCare Medicare	$272.00
Rate for Payer: Cash Price	$353.60
Rate for Payer: Cash Price	$353.60
Rate for Payer: Cash Price	$353.60
Rate for Payer: Devoted Health Medicare	$299.20
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$272.00
Rate for Payer: Health Management Network Commercial	$462.40
Rate for Payer: Humana Medicare	$272.00
Rate for Payer: Kaiser Permanente Commercial	$489.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$272.00
Rate for Payer: MDX Hawaii PPO	$527.68
Rate for Payer: Ohana Health Plan Medicaid	$272.00
Rate for Payer: Ohana Health Plan Medicare	$272.00
Rate for Payer: UnitedHealthcare Medicaid	$12.77
Rate for Payer: UnitedHealthcare Medicare	$272.00
Rate for Payer: University Health Alliance Commercial	$396.52

Gastric Intubation and Aspiraton Therapeutic

Facility

$544.00

Service Code	HCPCS 43753
Hospital Charge Code	12647404
Hospital Revenue Code	361
Min. Negotiated Rate	$462.40
Max. Negotiated Rate	$527.68
Rate for Payer: Cash Price	$353.60
Rate for Payer: Health Management Network Commercial	$462.40
Rate for Payer: Kaiser Permanente Commercial	$489.60
Rate for Payer: MDX Hawaii PPO	$527.68

Gastric Intubation and Aspiraton Therapeutic

Professional

Both

$301.00

Service Code	HCPCS 43753
Hospital Charge Code	12647404
Hospital Revenue Code	960
Min. Negotiated Rate	$19.66
Max. Negotiated Rate	$255.85
Rate for Payer: AlohaCare Medicaid	$20.68
Rate for Payer: AlohaCare Medicare	$19.66
Rate for Payer: Cash Price	$195.65
Rate for Payer: Cash Price	$195.65
Rate for Payer: Devoted Health Medicare	$21.63
Rate for Payer: Hawaii Medical Service Association Medicare	$19.66
Rate for Payer: Health Management Network Commercial	$255.85
Rate for Payer: Kaiser Permanente Commercial	$21.63
Rate for Payer: Kaiser Permanente Medicaid	$21.63
Rate for Payer: Kaiser Permanente Medicare	$21.63
Rate for Payer: Ohana Health Plan Medicaid	$20.68
Rate for Payer: Ohana Health Plan Medicare	$19.66
Rate for Payer: UnitedHealthcare Medicaid	$20.68
Rate for Payer: UnitedHealthcare Medicare	$19.66

GASTROINTESTINAL HEMORRHAGE WITH CC

Facility

$22,971.90

Service Code	MSDRG 378
Min. Negotiated Rate	$22,971.90
Max. Negotiated Rate	$22,971.90
Rate for Payer: Hawaii Medical Service Association Commercial	$22,971.90

GASTROINTESTINAL HEMORRHAGE WITH MCC

Facility

$22,971.90

Service Code	MSDRG 377
Min. Negotiated Rate	$22,971.90
Max. Negotiated Rate	$22,971.90
Rate for Payer: Hawaii Medical Service Association Commercial	$22,971.90

GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC

Facility

$17,617.74

Service Code	MSDRG 379
Min. Negotiated Rate	$17,617.74
Max. Negotiated Rate	$17,617.74
Rate for Payer: Hawaii Medical Service Association Commercial	$17,617.74

GASTROINTESTINAL OBSTRUCTION WITH CC

Facility

$17,923.69

Service Code	MSDRG 389
Min. Negotiated Rate	$17,923.69
Max. Negotiated Rate	$17,923.69
Rate for Payer: Hawaii Medical Service Association Commercial	$17,923.69

GASTROINTESTINAL OBSTRUCTION WITH MCC

Facility

$20,192.83

Service Code	MSDRG 388
Min. Negotiated Rate	$20,192.83
Max. Negotiated Rate	$20,192.83
Rate for Payer: Hawaii Medical Service Association Commercial	$20,192.83

GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC

Facility

$14,277.76

Service Code	MSDRG 390
Min. Negotiated Rate	$14,277.76
Max. Negotiated Rate	$14,277.76
Rate for Payer: Hawaii Medical Service Association Commercial	$14,277.76

GASTROSTOMY 20FR. 50738 KIT

Facility

$282.00

Hospital Charge Code	8274194
Hospital Revenue Code	272
Min. Negotiated Rate	$141.00
Max. Negotiated Rate	$273.54
Rate for Payer: AlohaCare Medicaid	$141.00
Rate for Payer: AlohaCare Medicare	$141.00
Rate for Payer: Cash Price	$183.30
Rate for Payer: Devoted Health Medicare	$155.10
Rate for Payer: Hawaii Medical Service Association Medicare	$141.00
Rate for Payer: Hawaii Western Management Group Commercial	$267.90
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Humana Medicare	$141.00
Rate for Payer: Kaiser Permanente Commercial	$253.80
Rate for Payer: Kaiser Permanente Medicaid	$143.82
Rate for Payer: Kaiser Permanente Medicare	$141.00
Rate for Payer: MDX Hawaii PPO	$273.54
Rate for Payer: Ohana Health Plan Medicaid	$141.00
Rate for Payer: Ohana Health Plan Medicare	$141.00
Rate for Payer: UnitedHealthcare Medicare	$141.00
Rate for Payer: University Health Alliance Commercial	$205.55

GASTROSTOMY 20FR. 50738 KIT

Facility

$282.00

Hospital Charge Code	8274194
Hospital Revenue Code	272
Min. Negotiated Rate	$239.70
Max. Negotiated Rate	$273.54
Rate for Payer: Cash Price	$183.30
Rate for Payer: Health Management Network Commercial	$239.70
Rate for Payer: Kaiser Permanente Commercial	$253.80
Rate for Payer: MDX Hawaii PPO	$273.54

GASTROSTOMY 20FR. 52354 KIT

Facility

$280.00

Hospital Charge Code	8274195
Hospital Revenue Code	272
Min. Negotiated Rate	$238.00
Max. Negotiated Rate	$271.60
Rate for Payer: Cash Price	$182.00
Rate for Payer: Health Management Network Commercial	$238.00
Rate for Payer: Kaiser Permanente Commercial	$252.00
Rate for Payer: MDX Hawaii PPO	$271.60

GASTROSTOMY 20FR. 52354 KIT

Facility

$280.00

Hospital Charge Code	8274195
Hospital Revenue Code	272
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$271.60
Rate for Payer: AlohaCare Medicaid	$140.00
Rate for Payer: AlohaCare Medicare	$140.00
Rate for Payer: Cash Price	$182.00
Rate for Payer: Devoted Health Medicare	$154.00
Rate for Payer: Hawaii Medical Service Association Medicare	$140.00
Rate for Payer: Hawaii Western Management Group Commercial	$266.00
Rate for Payer: Health Management Network Commercial	$238.00
Rate for Payer: Humana Medicare	$140.00
Rate for Payer: Kaiser Permanente Commercial	$252.00
Rate for Payer: Kaiser Permanente Medicaid	$142.80
Rate for Payer: Kaiser Permanente Medicare	$140.00
Rate for Payer: MDX Hawaii PPO	$271.60
Rate for Payer: Ohana Health Plan Medicaid	$140.00
Rate for Payer: Ohana Health Plan Medicare	$140.00
Rate for Payer: UnitedHealthcare Medicare	$140.00
Rate for Payer: University Health Alliance Commercial	$204.09

GASTROSTOMY 24FR FEEDING TUBE SAFETY PEG PULL KIT

Facility

$354.00

Hospital Charge Code	8274196
Hospital Revenue Code	272
Min. Negotiated Rate	$300.90
Max. Negotiated Rate	$343.38
Rate for Payer: Cash Price	$230.10
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: MDX Hawaii PPO	$343.38

GASTROSTOMY 24FR FEEDING TUBE SAFETY PEG PULL KIT

Facility

$354.00

Hospital Charge Code	8274196
Hospital Revenue Code	272
Min. Negotiated Rate	$177.00
Max. Negotiated Rate	$343.38
Rate for Payer: AlohaCare Medicaid	$177.00
Rate for Payer: AlohaCare Medicare	$177.00
Rate for Payer: Cash Price	$230.10
Rate for Payer: Devoted Health Medicare	$194.70
Rate for Payer: Hawaii Medical Service Association Medicare	$177.00
Rate for Payer: Hawaii Western Management Group Commercial	$336.30
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Humana Medicare	$177.00
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: Kaiser Permanente Medicaid	$180.54
Rate for Payer: Kaiser Permanente Medicare	$177.00
Rate for Payer: MDX Hawaii PPO	$343.38
Rate for Payer: Ohana Health Plan Medicaid	$177.00
Rate for Payer: Ohana Health Plan Medicare	$177.00
Rate for Payer: UnitedHealthcare Medicare	$177.00
Rate for Payer: University Health Alliance Commercial	$258.03

Know your out-of-pocket cost for care.

All Charges