Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

LIDOCAINE 5 % TOPICAL OINTMENT [41831]

Facility

IP

$905.00

Service Code	NDC 33342040535
Hospital Revenue Code	250
Min. Negotiated Rate	$769.25
Max. Negotiated Rate	$877.85
Rate for Payer: Cash Price	$543.00
Rate for Payer: Health Management Network Commercial	$769.25
Rate for Payer: Kaiser Permanente Commercial	$814.50
Rate for Payer: MDX Hawaii PPO	$877.85

LIDOCAINE 5 % TOPICAL OINTMENT [41831]

Facility

OP

$950.00

Service Code	NDC 68462041820
Hospital Revenue Code	637
Min. Negotiated Rate	$475.00
Max. Negotiated Rate	$921.50
Rate for Payer: AlohaCare Medicaid	$475.00
Rate for Payer: AlohaCare Medicare	$722.00
Rate for Payer: Cash Price	$570.00
Rate for Payer: Devoted Health Medicare	$798.00
Rate for Payer: Hawaii Medical Service Association Medicare	$722.00
Rate for Payer: Hawaii Western Management Group Commercial	$902.50
Rate for Payer: Health Management Network Commercial	$807.50
Rate for Payer: Humana Medicare	$722.00
Rate for Payer: Kaiser Permanente Commercial	$855.00
Rate for Payer: Kaiser Permanente Medicaid	$484.50
Rate for Payer: Kaiser Permanente Medicare	$722.00
Rate for Payer: MDX Hawaii PPO	$921.50
Rate for Payer: Ohana Health Plan Medicaid	$722.00
Rate for Payer: Ohana Health Plan Medicare	$722.00
Rate for Payer: UnitedHealthcare Medicare	$722.00
Rate for Payer: University Health Alliance Commercial	$692.46

LIDOCAINE 5 % TOPICAL OINTMENT [41831]

Facility

IP

$950.00

Service Code	NDC 68462041820
Hospital Revenue Code	250
Min. Negotiated Rate	$807.50
Max. Negotiated Rate	$921.50
Rate for Payer: Cash Price	$570.00
Rate for Payer: Health Management Network Commercial	$807.50
Rate for Payer: Kaiser Permanente Commercial	$855.00
Rate for Payer: MDX Hawaii PPO	$921.50

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

IP

$84.00

Service Code	NDC 61959000130
Hospital Revenue Code	250
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$50.40
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: MDX Hawaii PPO	$81.48

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

IP

$80.00

Service Code	NDC 63481068706
Hospital Revenue Code	250
Min. Negotiated Rate	$68.00
Max. Negotiated Rate	$77.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Health Management Network Commercial	$68.00
Rate for Payer: Kaiser Permanente Commercial	$72.00
Rate for Payer: MDX Hawaii PPO	$77.60

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

IP

$29.00

Service Code	NDC 00591267930
Hospital Revenue Code	250
Min. Negotiated Rate	$24.65
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$17.40
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Kaiser Permanente Commercial	$26.10
Rate for Payer: MDX Hawaii PPO	$28.13

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

OP

$29.00

Service Code	NDC 00591352530
Hospital Revenue Code	637
Min. Negotiated Rate	$14.50
Max. Negotiated Rate	$28.13
Rate for Payer: AlohaCare Medicaid	$14.50
Rate for Payer: AlohaCare Medicare	$22.04
Rate for Payer: Cash Price	$17.40
Rate for Payer: Devoted Health Medicare	$24.36
Rate for Payer: Hawaii Medical Service Association Medicare	$22.04
Rate for Payer: Hawaii Western Management Group Commercial	$27.55
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Humana Medicare	$22.04
Rate for Payer: Kaiser Permanente Commercial	$26.10
Rate for Payer: Kaiser Permanente Medicaid	$14.79
Rate for Payer: Kaiser Permanente Medicare	$22.04
Rate for Payer: MDX Hawaii PPO	$28.13
Rate for Payer: Ohana Health Plan Medicaid	$22.04
Rate for Payer: Ohana Health Plan Medicare	$22.04
Rate for Payer: UnitedHealthcare Medicare	$22.04
Rate for Payer: University Health Alliance Commercial	$21.14

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

OP

$12.00

Service Code	NDC 82347050505
Hospital Revenue Code	637
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$9.12
Rate for Payer: Cash Price	$7.20
Rate for Payer: Devoted Health Medicare	$10.08
Rate for Payer: Hawaii Medical Service Association Medicare	$9.12
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$9.12
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$9.12
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$9.12
Rate for Payer: Ohana Health Plan Medicare	$9.12
Rate for Payer: UnitedHealthcare Medicare	$9.12
Rate for Payer: University Health Alliance Commercial	$8.75

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

OP

$29.00

Service Code	NDC 00591267930
Hospital Revenue Code	637
Min. Negotiated Rate	$14.50
Max. Negotiated Rate	$28.13
Rate for Payer: AlohaCare Medicaid	$14.50
Rate for Payer: AlohaCare Medicare	$22.04
Rate for Payer: Cash Price	$17.40
Rate for Payer: Devoted Health Medicare	$24.36
Rate for Payer: Hawaii Medical Service Association Medicare	$22.04
Rate for Payer: Hawaii Western Management Group Commercial	$27.55
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Humana Medicare	$22.04
Rate for Payer: Kaiser Permanente Commercial	$26.10
Rate for Payer: Kaiser Permanente Medicaid	$14.79
Rate for Payer: Kaiser Permanente Medicare	$22.04
Rate for Payer: MDX Hawaii PPO	$28.13
Rate for Payer: Ohana Health Plan Medicaid	$22.04
Rate for Payer: Ohana Health Plan Medicare	$22.04
Rate for Payer: UnitedHealthcare Medicare	$22.04
Rate for Payer: University Health Alliance Commercial	$21.14

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

OP

$12.00

Service Code	NDC 82347050504
Hospital Revenue Code	637
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$9.12
Rate for Payer: Cash Price	$7.20
Rate for Payer: Devoted Health Medicare	$10.08
Rate for Payer: Hawaii Medical Service Association Medicare	$9.12
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$9.12
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$9.12
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$9.12
Rate for Payer: Ohana Health Plan Medicare	$9.12
Rate for Payer: UnitedHealthcare Medicare	$9.12
Rate for Payer: University Health Alliance Commercial	$8.75

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

IP

$12.00

Service Code	NDC 82347050505
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: Kaiser Permanente Commercial	$10.80
Rate for Payer: MDX Hawaii PPO	$11.64

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

IP

$29.00

Service Code	NDC 00591352530
Hospital Revenue Code	250
Min. Negotiated Rate	$24.65
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$17.40
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Kaiser Permanente Commercial	$26.10
Rate for Payer: MDX Hawaii PPO	$28.13

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

IP

$12.00

Service Code	NDC 82347050504
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: Kaiser Permanente Commercial	$10.80
Rate for Payer: MDX Hawaii PPO	$11.64

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

OP

$80.00

Service Code	NDC 63481068706
Hospital Revenue Code	637
Min. Negotiated Rate	$40.00
Max. Negotiated Rate	$77.60
Rate for Payer: AlohaCare Medicaid	$40.00
Rate for Payer: AlohaCare Medicare	$60.80
Rate for Payer: Cash Price	$48.00
Rate for Payer: Devoted Health Medicare	$67.20
Rate for Payer: Hawaii Medical Service Association Medicare	$60.80
Rate for Payer: Hawaii Western Management Group Commercial	$76.00
Rate for Payer: Health Management Network Commercial	$68.00
Rate for Payer: Humana Medicare	$60.80
Rate for Payer: Kaiser Permanente Commercial	$72.00
Rate for Payer: Kaiser Permanente Medicaid	$40.80
Rate for Payer: Kaiser Permanente Medicare	$60.80
Rate for Payer: MDX Hawaii PPO	$77.60
Rate for Payer: Ohana Health Plan Medicaid	$60.80
Rate for Payer: Ohana Health Plan Medicare	$60.80
Rate for Payer: UnitedHealthcare Medicare	$60.80
Rate for Payer: University Health Alliance Commercial	$58.31

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

OP

$84.00

Service Code	NDC 61959000130
Hospital Revenue Code	637
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$81.48
Rate for Payer: AlohaCare Medicaid	$42.00
Rate for Payer: AlohaCare Medicare	$63.84
Rate for Payer: Cash Price	$50.40
Rate for Payer: Devoted Health Medicare	$70.56
Rate for Payer: Hawaii Medical Service Association Medicare	$63.84
Rate for Payer: Hawaii Western Management Group Commercial	$79.80
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Humana Medicare	$63.84
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: Kaiser Permanente Medicaid	$42.84
Rate for Payer: Kaiser Permanente Medicare	$63.84
Rate for Payer: MDX Hawaii PPO	$81.48
Rate for Payer: Ohana Health Plan Medicaid	$63.84
Rate for Payer: Ohana Health Plan Medicare	$63.84
Rate for Payer: UnitedHealthcare Medicare	$63.84
Rate for Payer: University Health Alliance Commercial	$61.23

LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [10431]

Facility

IP

$99.00

Service Code	NDC 63323048927
Hospital Revenue Code	250
Min. Negotiated Rate	$84.15
Max. Negotiated Rate	$96.03
Rate for Payer: Cash Price	$59.40
Rate for Payer: Health Management Network Commercial	$84.15
Rate for Payer: Kaiser Permanente Commercial	$89.10
Rate for Payer: MDX Hawaii PPO	$96.03

LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [10431]

Facility

IP

$99.00

Service Code	NDC 63323048902
Hospital Revenue Code	250
Min. Negotiated Rate	$84.15
Max. Negotiated Rate	$96.03
Rate for Payer: Cash Price	$59.40
Rate for Payer: Health Management Network Commercial	$84.15
Rate for Payer: Kaiser Permanente Commercial	$89.10
Rate for Payer: MDX Hawaii PPO	$96.03

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: Kaiser Permanente Commercial	$10.80
Rate for Payer: MDX Hawaii PPO	$11.64

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

Facility

IP

$14.00

Service Code	NDC 00409427601
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: MDX Hawaii PPO	$13.58

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	$5.40
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: MDX Hawaii PPO	$4.85

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

Facility

IP

$14.00

Service Code	NDC 00409427616
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: MDX Hawaii PPO	$13.58

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: Kaiser Permanente Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$16.49

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

Facility

OP

$17.00

Service Code	HCPCS J2003
Hospital Revenue Code	636
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$16.49
Rate for Payer: AlohaCare Medicaid	$8.50
Rate for Payer: AlohaCare Medicare	$12.92
Rate for Payer: Cash Price	$10.20
Rate for Payer: Devoted Health Medicare	$14.28
Rate for Payer: Hawaii Medical Service Association Medicare	$12.92
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Humana Medicare	$12.92
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicare	$12.92
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: Ohana Health Plan Medicaid	$12.92
Rate for Payer: Ohana Health Plan Medicare	$12.92
Rate for Payer: UnitedHealthcare Medicaid	$10.20
Rate for Payer: UnitedHealthcare Medicare	$12.92
Rate for Payer: University Health Alliance Commercial	$12.39

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]

Facility

OP

$47.00

Service Code	NDC 72888012526
Hospital Revenue Code	637
Min. Negotiated Rate	$23.50
Max. Negotiated Rate	$45.59
Rate for Payer: AlohaCare Medicaid	$23.50
Rate for Payer: AlohaCare Medicare	$35.72
Rate for Payer: Cash Price	$28.20
Rate for Payer: Devoted Health Medicare	$39.48
Rate for Payer: Hawaii Medical Service Association Medicare	$35.72
Rate for Payer: Hawaii Western Management Group Commercial	$44.65
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: Humana Medicare	$35.72
Rate for Payer: Kaiser Permanente Commercial	$42.30
Rate for Payer: Kaiser Permanente Medicaid	$23.97
Rate for Payer: Kaiser Permanente Medicare	$35.72
Rate for Payer: MDX Hawaii PPO	$45.59
Rate for Payer: Ohana Health Plan Medicaid	$35.72
Rate for Payer: Ohana Health Plan Medicare	$35.72
Rate for Payer: UnitedHealthcare Medicare	$35.72
Rate for Payer: University Health Alliance Commercial	$34.26

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: Kaiser Permanente Commercial	$42.30
Rate for Payer: MDX Hawaii PPO	$45.59

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