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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]

Facility

IP

$2.00

Service Code	NDC 63323020110
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: MDX Hawaii PPO	$8.73

LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]

Facility

IP

$12.00

Service Code	NDC 63323020103
Hospital Revenue Code	250
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.20
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: MDX Hawaii PPO	$11.64

LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION [4454]

Facility

OP

$17.00

Service Code	HCPCS J2003
Hospital Revenue Code	636
Min. Negotiated Rate	$8.67
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$10.71
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: UnitedHealthcare Medicaid	$10.20
Rate for Payer: University Health Alliance Commercial	$12.39

LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION [4454]

Facility

IP

$17.00

Service Code	HCPCS J2003
Hospital Revenue Code	250
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: MDX Hawaii PPO	$16.49

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]

Facility

IP

$47.00

Service Code	NDC 72888012526
Hospital Revenue Code	250
Min. Negotiated Rate	$39.95
Max. Negotiated Rate	$45.59
Rate for Payer: Cash Price	$28.20
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: MDX Hawaii PPO	$45.59

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]

Facility

OP

$47.00

Service Code	NDC 72888012526
Hospital Revenue Code	637
Min. Negotiated Rate	$23.97
Max. Negotiated Rate	$45.59
Rate for Payer: Cash Price	$28.20
Rate for Payer: Hawaii Western Management Group Commercial	$44.65
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: Kaiser Permanente Commercial	$29.61
Rate for Payer: Kaiser Permanente Medicaid	$23.97
Rate for Payer: MDX Hawaii PPO	$45.59
Rate for Payer: University Health Alliance Commercial	$34.26

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]

Facility

OP

$27.00

Service Code	NDC 00121495015
Hospital Revenue Code	637
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$17.01
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: University Health Alliance Commercial	$19.68

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]

Facility

IP

$27.00

Service Code	NDC 00121495040
Hospital Revenue Code	250
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: MDX Hawaii PPO	$26.19

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]

Facility

IP

$27.00

Service Code	NDC 00121495015
Hospital Revenue Code	250
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: MDX Hawaii PPO	$26.19

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]

Facility

OP

$27.00

Service Code	NDC 00121495040
Hospital Revenue Code	637
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$17.01
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: University Health Alliance Commercial	$19.68

LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]

Facility

OP

$168.00

Service Code	NDC 00054350547
Hospital Revenue Code	637
Min. Negotiated Rate	$85.68
Max. Negotiated Rate	$162.96
Rate for Payer: Cash Price	$100.80
Rate for Payer: Hawaii Western Management Group Commercial	$159.60
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Kaiser Permanente Commercial	$105.84
Rate for Payer: Kaiser Permanente Medicaid	$85.68
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: University Health Alliance Commercial	$122.46

LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]

Facility

OP

$227.00

Service Code	NDC 70954051810
Hospital Revenue Code	637
Min. Negotiated Rate	$115.77
Max. Negotiated Rate	$220.19
Rate for Payer: Cash Price	$136.20
Rate for Payer: Hawaii Western Management Group Commercial	$215.65
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Kaiser Permanente Commercial	$143.01
Rate for Payer: Kaiser Permanente Medicaid	$115.77
Rate for Payer: MDX Hawaii PPO	$220.19
Rate for Payer: University Health Alliance Commercial	$165.46

LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]

Facility

IP

$227.00

Service Code	NDC 70954051810
Hospital Revenue Code	250
Min. Negotiated Rate	$192.95
Max. Negotiated Rate	$220.19
Rate for Payer: Cash Price	$136.20
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: MDX Hawaii PPO	$220.19

LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]

Facility

IP

$168.00

Service Code	NDC 00054350547
Hospital Revenue Code	250
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$162.96
Rate for Payer: Cash Price	$100.80
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: MDX Hawaii PPO	$162.96

LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION [43717]

Facility

OP

$109.00

Service Code	NDC 76329630005
Hospital Revenue Code	637
Min. Negotiated Rate	$55.59
Max. Negotiated Rate	$105.73
Rate for Payer: Cash Price	$65.40
Rate for Payer: Hawaii Western Management Group Commercial	$103.55
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Kaiser Permanente Commercial	$68.67
Rate for Payer: Kaiser Permanente Medicaid	$55.59
Rate for Payer: MDX Hawaii PPO	$105.73
Rate for Payer: University Health Alliance Commercial	$79.45

LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION [43717]

Facility

IP

$109.00

Service Code	NDC 76329630005
Hospital Revenue Code	250
Min. Negotiated Rate	$92.65
Max. Negotiated Rate	$105.73
Rate for Payer: Cash Price	$65.40
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: MDX Hawaii PPO	$105.73

LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [166252]

Facility

IP

$31.00

Service Code	NDC 00409132315
Hospital Revenue Code	250
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: MDX Hawaii PPO	$30.07

LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [166252]

Facility

IP

$31.00

Service Code	NDC 00409132305
Hospital Revenue Code	250
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: MDX Hawaii PPO	$30.07

LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [166252]

Facility

IP

$32.00

Service Code	NDC 00409490334
Hospital Revenue Code	250
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: MDX Hawaii PPO	$31.04

LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [166252]

Facility

IP

$38.00

Service Code	NDC 76329339001
Hospital Revenue Code	250
Min. Negotiated Rate	$32.30
Max. Negotiated Rate	$36.86
Rate for Payer: Cash Price	$22.80
Rate for Payer: Health Management Network Commercial	$32.30
Rate for Payer: MDX Hawaii PPO	$36.86

LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]

Facility

IP

$10.00

Service Code	NDC 55150015974
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.00
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: MDX Hawaii PPO	$9.70

LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]

Facility

IP

$15.00

Service Code	NDC 55150016205
Hospital Revenue Code	250
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: MDX Hawaii PPO	$14.55

LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]

Facility

IP

$11.00

Service Code	NDC 55150016102
Hospital Revenue Code	250
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: MDX Hawaii PPO	$10.67

LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]

Facility

IP

$11.00

Service Code	NDC 73293000102
Hospital Revenue Code	250
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: MDX Hawaii PPO	$10.67

LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]

Facility

IP

$3.00

Service Code	NDC 73293000101
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: MDX Hawaii PPO	$20.37

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