Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

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

$3.24

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 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

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

$7.46

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	$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

$7.65

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	$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 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 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 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

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

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	$93.44

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

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

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	$58.36

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

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	$133.28

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	$304.64

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	$23.59
Rate for Payer: Kaiser Permanente Medicaid	$23.59
Rate for Payer: Kaiser Permanente Medicare	$23.59
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

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

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