Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

levothyroxine 75 mcg (0.075 mg) Tab UD [KMC]

Facility

$3.00

Service Code	NDC 72305007530
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

levothyroxine 75 mcg (0.075 mg) Tab UD [KMC]

Facility

$3.00

Service Code	NDC 72305007530
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

levothyroxine 88 mcg (0.088 mg) Tab [KMC]

Facility

$3.00

Service Code	NDC 72305008830
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

levothyroxine 88 mcg (0.088 mg) Tab [KMC]

Facility

$3.00

Service Code	NDC 72305008830
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

LH DLS

Facility

$132.00

Service Code	HCPCS 83002
Hospital Charge Code	422830025
Hospital Revenue Code	301
Min. Negotiated Rate	$18.52
Max. Negotiated Rate	$128.04
Rate for Payer: AlohaCare Medicaid	$66.00
Rate for Payer: AlohaCare Medicare	$55.44
Rate for Payer: Cash Price	$85.80
Rate for Payer: Cash Price	$85.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$121.44
Rate for Payer: Devoted Health Medicare	$55.44
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$25.60
Rate for Payer: Hawaii Medical Service Association Commercial	$23.15
Rate for Payer: Hawaii Medical Service Association Medicare	$55.44
Rate for Payer: Hawaii Western Management Group Commercial	$18.52
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Humana Medicare	$55.44
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: Kaiser Permanente Medicare	$55.44
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: Ohana Health Plan Medicaid	$55.44
Rate for Payer: Ohana Health Plan Medicare	$55.44
Rate for Payer: UnitedHealthcare Medicaid	$25.60
Rate for Payer: UnitedHealthcare Medicare	$55.44
Rate for Payer: University Health Alliance Commercial	$47.88

LH DLS

Facility

$132.00

Service Code	HCPCS 83002
Hospital Charge Code	422830025
Hospital Revenue Code	301
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$85.80
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: MDX Hawaii PPO	$128.04

lidocaine 1% PF Inj Sol 2 mL [KMC]

Facility

$5.35

Service Code	HCPCS J2001
Hospital Revenue Code	636
Min. Negotiated Rate	$4.55
Max. Negotiated Rate	$5.19
Rate for Payer: Cash Price	$3.48
Rate for Payer: Health Management Network Commercial	$4.55
Rate for Payer: Kaiser Permanente Commercial	$4.82
Rate for Payer: MDX Hawaii PPO	$5.19

lidocaine 1% PF Inj Sol 2 mL [KMC]

Facility

$5.35

Service Code	HCPCS J2001
Hospital Revenue Code	636
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$5.19
Rate for Payer: AlohaCare Medicaid	$2.67
Rate for Payer: AlohaCare Medicare	$2.25
Rate for Payer: Cash Price	$3.48
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.92
Rate for Payer: Devoted Health Medicare	$2.25
Rate for Payer: Hawaii Medical Service Association Medicare	$2.25
Rate for Payer: Hawaii Western Management Group Commercial	$5.08
Rate for Payer: Health Management Network Commercial	$4.55
Rate for Payer: Humana Medicare	$2.25
Rate for Payer: Kaiser Permanente Commercial	$4.82
Rate for Payer: Kaiser Permanente Medicaid	$2.73
Rate for Payer: Kaiser Permanente Medicare	$2.25
Rate for Payer: MDX Hawaii PPO	$5.19
Rate for Payer: Ohana Health Plan Medicaid	$2.25
Rate for Payer: Ohana Health Plan Medicare	$2.25
Rate for Payer: UnitedHealthcare Medicaid	$3.21
Rate for Payer: UnitedHealthcare Medicare	$2.25
Rate for Payer: University Health Alliance Commercial	$3.90

lidocaine 1% PF Inj Sol 5 mL [KMC]

Facility

$3.12

Service Code	HCPCS J2001
Hospital Revenue Code	636
Min. Negotiated Rate	$2.65
Max. Negotiated Rate	$3.03
Rate for Payer: Cash Price	$2.03
Rate for Payer: Health Management Network Commercial	$2.65
Rate for Payer: Kaiser Permanente Commercial	$2.81
Rate for Payer: MDX Hawaii PPO	$3.03

lidocaine 1% PF Inj Sol 5 mL [KMC]

Facility

$3.12

Service Code	HCPCS J2001
Hospital Revenue Code	636
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$3.03
Rate for Payer: AlohaCare Medicaid	$1.56
Rate for Payer: AlohaCare Medicare	$1.31
Rate for Payer: Cash Price	$2.03
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.87
Rate for Payer: Devoted Health Medicare	$1.31
Rate for Payer: Hawaii Medical Service Association Medicare	$1.31
Rate for Payer: Hawaii Western Management Group Commercial	$2.96
Rate for Payer: Health Management Network Commercial	$2.65
Rate for Payer: Humana Medicare	$1.31
Rate for Payer: Kaiser Permanente Commercial	$2.81
Rate for Payer: Kaiser Permanente Medicaid	$1.59
Rate for Payer: Kaiser Permanente Medicare	$1.31
Rate for Payer: MDX Hawaii PPO	$3.03
Rate for Payer: Ohana Health Plan Medicaid	$1.31
Rate for Payer: Ohana Health Plan Medicare	$1.31
Rate for Payer: UnitedHealthcare Medicaid	$1.87
Rate for Payer: UnitedHealthcare Medicare	$1.31
Rate for Payer: University Health Alliance Commercial	$2.27

lidocaine 2% (20 mg/5 mL) syringe [KMC]

Facility

$4.11

Service Code	HCPCS J2001
Hospital Revenue Code	636
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$3.99
Rate for Payer: Cash Price	$2.67
Rate for Payer: Health Management Network Commercial	$3.49
Rate for Payer: Kaiser Permanente Commercial	$3.70
Rate for Payer: MDX Hawaii PPO	$3.99

lidocaine 2% (20 mg/5 mL) syringe [KMC]

Facility

$4.11

Service Code	HCPCS J2001
Hospital Revenue Code	636
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$3.99
Rate for Payer: AlohaCare Medicaid	$2.06
Rate for Payer: AlohaCare Medicare	$1.73
Rate for Payer: Cash Price	$2.67
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.78
Rate for Payer: Devoted Health Medicare	$1.73
Rate for Payer: Hawaii Medical Service Association Medicare	$1.73
Rate for Payer: Hawaii Western Management Group Commercial	$3.90
Rate for Payer: Health Management Network Commercial	$3.49
Rate for Payer: Humana Medicare	$1.73
Rate for Payer: Kaiser Permanente Commercial	$3.70
Rate for Payer: Kaiser Permanente Medicaid	$2.10
Rate for Payer: Kaiser Permanente Medicare	$1.73
Rate for Payer: MDX Hawaii PPO	$3.99
Rate for Payer: Ohana Health Plan Medicaid	$1.73
Rate for Payer: Ohana Health Plan Medicare	$1.73
Rate for Payer: UnitedHealthcare Medicaid	$2.47
Rate for Payer: UnitedHealthcare Medicare	$1.73
Rate for Payer: University Health Alliance Commercial	$3.00

lidocaine 2% topical Jelly [KMC]

Facility

$6.24

Service Code	NDC 17478071110
Hospital Revenue Code	250
Min. Negotiated Rate	$5.30
Max. Negotiated Rate	$6.05
Rate for Payer: Cash Price	$4.06
Rate for Payer: Health Management Network Commercial	$5.30
Rate for Payer: Kaiser Permanente Commercial	$5.62
Rate for Payer: MDX Hawaii PPO	$6.05

lidocaine 2% topical Jelly [KMC]

Facility

$6.24

Service Code	NDC 17478071110
Hospital Revenue Code	250
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$6.05
Rate for Payer: AlohaCare Medicaid	$3.12
Rate for Payer: AlohaCare Medicare	$2.62
Rate for Payer: Cash Price	$4.06
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.74
Rate for Payer: Devoted Health Medicare	$2.62
Rate for Payer: Hawaii Medical Service Association Medicare	$2.62
Rate for Payer: Hawaii Western Management Group Commercial	$5.93
Rate for Payer: Health Management Network Commercial	$5.30
Rate for Payer: Humana Medicare	$2.62
Rate for Payer: Kaiser Permanente Commercial	$5.62
Rate for Payer: Kaiser Permanente Medicaid	$3.18
Rate for Payer: Kaiser Permanente Medicare	$2.62
Rate for Payer: MDX Hawaii PPO	$6.05
Rate for Payer: Ohana Health Plan Medicaid	$2.62
Rate for Payer: Ohana Health Plan Medicare	$2.62
Rate for Payer: UnitedHealthcare Medicaid	$3.74
Rate for Payer: UnitedHealthcare Medicare	$2.62
Rate for Payer: University Health Alliance Commercial	$4.55

lidocaine 2% Viscous Oral Soln [KMC]

Facility

$0.53

Service Code	NDC 16714009701
Hospital Revenue Code	250
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.51
Rate for Payer: AlohaCare Medicaid	$0.27
Rate for Payer: AlohaCare Medicare	$0.22
Rate for Payer: Cash Price	$0.34
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.49
Rate for Payer: Devoted Health Medicare	$0.22
Rate for Payer: Hawaii Medical Service Association Medicare	$0.22
Rate for Payer: Hawaii Western Management Group Commercial	$0.50
Rate for Payer: Health Management Network Commercial	$0.45
Rate for Payer: Humana Medicare	$0.22
Rate for Payer: Kaiser Permanente Commercial	$0.48
Rate for Payer: Kaiser Permanente Medicaid	$0.27
Rate for Payer: Kaiser Permanente Medicare	$0.22
Rate for Payer: MDX Hawaii PPO	$0.51
Rate for Payer: Ohana Health Plan Medicaid	$0.22
Rate for Payer: Ohana Health Plan Medicare	$0.22
Rate for Payer: UnitedHealthcare Medicaid	$0.32
Rate for Payer: UnitedHealthcare Medicare	$0.22
Rate for Payer: University Health Alliance Commercial	$0.39

lidocaine 2% Viscous Oral Soln [KMC]

Facility

$0.53

Service Code	NDC 16714009701
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.34
Rate for Payer: Health Management Network Commercial	$0.45
Rate for Payer: Kaiser Permanente Commercial	$0.48
Rate for Payer: MDX Hawaii PPO	$0.51

lidocaine 4% (40mg/mL) ORAL/TOPICAL soln [KMC]

Facility

$5.17

Service Code	NDC 00527600480
Hospital Revenue Code	250
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$5.01
Rate for Payer: AlohaCare Medicaid	$2.58
Rate for Payer: AlohaCare Medicare	$2.17
Rate for Payer: Cash Price	$3.36
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.76
Rate for Payer: Devoted Health Medicare	$2.17
Rate for Payer: Hawaii Medical Service Association Medicare	$2.17
Rate for Payer: Hawaii Western Management Group Commercial	$4.91
Rate for Payer: Health Management Network Commercial	$4.39
Rate for Payer: Humana Medicare	$2.17
Rate for Payer: Kaiser Permanente Commercial	$4.65
Rate for Payer: Kaiser Permanente Medicaid	$2.64
Rate for Payer: Kaiser Permanente Medicare	$2.17
Rate for Payer: MDX Hawaii PPO	$5.01
Rate for Payer: Ohana Health Plan Medicaid	$2.17
Rate for Payer: Ohana Health Plan Medicare	$2.17
Rate for Payer: UnitedHealthcare Medicaid	$3.10
Rate for Payer: UnitedHealthcare Medicare	$2.17
Rate for Payer: University Health Alliance Commercial	$3.77

lidocaine 4% (40mg/mL) ORAL/TOPICAL soln [KMC]

Facility

$5.17

Service Code	NDC 00527600480
Hospital Revenue Code	250
Min. Negotiated Rate	$4.39
Max. Negotiated Rate	$5.01
Rate for Payer: Cash Price	$3.36
Rate for Payer: Health Management Network Commercial	$4.39
Rate for Payer: Kaiser Permanente Commercial	$4.65
Rate for Payer: MDX Hawaii PPO	$5.01

lidocaine 4% topical Cream [KMC]

Facility

$4.32

Service Code	NDC 47781057047
Hospital Revenue Code	250
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$4.19
Rate for Payer: AlohaCare Medicaid	$2.16
Rate for Payer: AlohaCare Medicare	$1.81
Rate for Payer: Cash Price	$2.81
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.97
Rate for Payer: Devoted Health Medicare	$1.81
Rate for Payer: Hawaii Medical Service Association Medicare	$1.81
Rate for Payer: Hawaii Western Management Group Commercial	$4.10
Rate for Payer: Health Management Network Commercial	$3.67
Rate for Payer: Humana Medicare	$1.81
Rate for Payer: Kaiser Permanente Commercial	$3.89
Rate for Payer: Kaiser Permanente Medicaid	$2.20
Rate for Payer: Kaiser Permanente Medicare	$1.81
Rate for Payer: MDX Hawaii PPO	$4.19
Rate for Payer: Ohana Health Plan Medicaid	$1.81
Rate for Payer: Ohana Health Plan Medicare	$1.81
Rate for Payer: UnitedHealthcare Medicaid	$2.59
Rate for Payer: UnitedHealthcare Medicare	$1.81
Rate for Payer: University Health Alliance Commercial	$3.15

lidocaine 4% topical Cream [KMC]

Facility

$4.32

Service Code	NDC 47781057047
Hospital Revenue Code	250
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$4.19
Rate for Payer: Cash Price	$2.81
Rate for Payer: Health Management Network Commercial	$3.67
Rate for Payer: Kaiser Permanente Commercial	$3.89
Rate for Payer: MDX Hawaii PPO	$4.19

lidocaine 5%-0.4% Sol [KMC]

Facility

$0.32

Service Code	HCPCS J2001
Hospital Revenue Code	636
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.31
Rate for Payer: Cash Price	$0.21
Rate for Payer: Health Management Network Commercial	$0.27
Rate for Payer: Kaiser Permanente Commercial	$0.29
Rate for Payer: MDX Hawaii PPO	$0.31

lidocaine 5%-0.4% Sol [KMC]

Facility

$0.32

Service Code	HCPCS J2001
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.31
Rate for Payer: AlohaCare Medicaid	$0.16
Rate for Payer: AlohaCare Medicare	$0.13
Rate for Payer: Cash Price	$0.21
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.29
Rate for Payer: Devoted Health Medicare	$0.13
Rate for Payer: Hawaii Medical Service Association Medicare	$0.13
Rate for Payer: Hawaii Western Management Group Commercial	$0.30
Rate for Payer: Health Management Network Commercial	$0.27
Rate for Payer: Humana Medicare	$0.13
Rate for Payer: Kaiser Permanente Commercial	$0.29
Rate for Payer: Kaiser Permanente Medicaid	$0.16
Rate for Payer: Kaiser Permanente Medicare	$0.13
Rate for Payer: MDX Hawaii PPO	$0.31
Rate for Payer: Ohana Health Plan Medicaid	$0.13
Rate for Payer: Ohana Health Plan Medicare	$0.13
Rate for Payer: UnitedHealthcare Medicaid	$0.19
Rate for Payer: UnitedHealthcare Medicare	$0.13
Rate for Payer: University Health Alliance Commercial	$0.23

LIDOCAINE INJECTION

Professional

Both

$5.00

Service Code	HCPCS J2001
Hospital Revenue Code	636
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$5.42
Rate for Payer: Cash Price	$3.25
Rate for Payer: Cash Price	$3.25
Rate for Payer: Hawaii Western Management Group Commercial	$5.42
Rate for Payer: Health Management Network Commercial	$4.25

lidocaine-prilocaine Top 2.5%-2.5% Crm [KMC]

Facility

$7.93

Service Code	NDC 00168035755
Hospital Revenue Code	250
Min. Negotiated Rate	$3.33
Max. Negotiated Rate	$7.69
Rate for Payer: AlohaCare Medicaid	$3.96
Rate for Payer: AlohaCare Medicare	$3.33
Rate for Payer: Cash Price	$5.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7.30
Rate for Payer: Devoted Health Medicare	$3.33
Rate for Payer: Hawaii Medical Service Association Medicare	$3.33
Rate for Payer: Hawaii Western Management Group Commercial	$7.53
Rate for Payer: Health Management Network Commercial	$6.74
Rate for Payer: Humana Medicare	$3.33
Rate for Payer: Kaiser Permanente Commercial	$7.14
Rate for Payer: Kaiser Permanente Medicaid	$4.04
Rate for Payer: Kaiser Permanente Medicare	$3.33
Rate for Payer: MDX Hawaii PPO	$7.69
Rate for Payer: Ohana Health Plan Medicaid	$3.33
Rate for Payer: Ohana Health Plan Medicare	$3.33
Rate for Payer: UnitedHealthcare Medicaid	$4.76
Rate for Payer: UnitedHealthcare Medicare	$3.33
Rate for Payer: University Health Alliance Commercial	$5.78

lidocaine-prilocaine Top 2.5%-2.5% Crm [KMC]

Facility

$7.93

Service Code	NDC 00168035755
Hospital Revenue Code	250
Min. Negotiated Rate	$6.74
Max. Negotiated Rate	$7.69
Rate for Payer: Cash Price	$5.15
Rate for Payer: Health Management Network Commercial	$6.74
Rate for Payer: Kaiser Permanente Commercial	$7.14
Rate for Payer: MDX Hawaii PPO	$7.69

Know your out-of-pocket cost for care.

All Charges