Kau Hospital

All Charges

Charge

Type

Setting

Price

LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]

Facility

$34.00

Service Code	NDC 00409317803
Hospital Revenue Code	250
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$20.40
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$32.98

LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]

Facility

$24.00

Service Code	NDC 63323048227
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10430]

Facility

$24.00

Service Code	NDC 63323048327
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10430]

Facility

$24.00

Service Code	NDC 63323048303
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10430]

Facility

$14.00

Service Code	NDC 00409318201
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 2 % MUCOSAL JELLY IN APPLICATOR [169436]

Facility

$25.00

Service Code	NDC 25021067376
Hospital Revenue Code	637
Min. Negotiated Rate	$7.75
Max. Negotiated Rate	$24.25
Rate for Payer: AlohaCare Medicaid	$12.50
Rate for Payer: AlohaCare Medicare	$7.75
Rate for Payer: Cash Price	$15.00
Rate for Payer: Devoted Health Medicare	$8.50
Rate for Payer: Hawaii Medical Service Association Medicare	$7.75
Rate for Payer: Hawaii Western Management Group Commercial	$23.75
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Humana Medicare	$7.75
Rate for Payer: Kaiser Permanente Commercial	$22.50
Rate for Payer: Kaiser Permanente Medicaid	$12.75
Rate for Payer: Kaiser Permanente Medicare	$7.75
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: Ohana Health Plan Medicaid	$7.75
Rate for Payer: Ohana Health Plan Medicare	$7.75
Rate for Payer: UnitedHealthcare Medicare	$7.75
Rate for Payer: University Health Alliance Commercial	$18.22

LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [169436]

Facility

$25.00

Service Code	NDC 25021067376
Hospital Revenue Code	250
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$15.00
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Kaiser Permanente Commercial	$22.50
Rate for Payer: MDX Hawaii PPO	$24.25

LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL [166770]

Facility

$36.00

Service Code	NDC 70092161144
Hospital Revenue Code	637
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$34.92
Rate for Payer: AlohaCare Medicaid	$18.00
Rate for Payer: AlohaCare Medicare	$11.16
Rate for Payer: Cash Price	$21.60
Rate for Payer: Devoted Health Medicare	$12.24
Rate for Payer: Hawaii Medical Service Association Medicare	$11.16
Rate for Payer: Hawaii Western Management Group Commercial	$34.20
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Humana Medicare	$11.16
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: Kaiser Permanente Medicare	$11.16
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: Ohana Health Plan Medicaid	$11.16
Rate for Payer: Ohana Health Plan Medicare	$11.16
Rate for Payer: UnitedHealthcare Medicare	$11.16
Rate for Payer: University Health Alliance Commercial	$26.24

LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL [166770]

Facility

$36.00

Service Code	NDC 70092161144
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

LIDOCAINE 4 % TOPICAL CREAM [23461]

Facility

$15.00

Service Code	NDC 24357070106
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: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

LIDOCAINE 4 % TOPICAL CREAM [23461]

Facility

$15.00

Service Code	NDC 24357070105
Hospital Revenue Code	637
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$4.65
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$5.10
Rate for Payer: Hawaii Medical Service Association Medicare	$4.65
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$4.65
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$4.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$4.65
Rate for Payer: Ohana Health Plan Medicare	$4.65
Rate for Payer: UnitedHealthcare Medicare	$4.65
Rate for Payer: University Health Alliance Commercial	$10.93

LIDOCAINE 4 % TOPICAL CREAM [23461]

Facility

$15.00

Service Code	NDC 24357070106
Hospital Revenue Code	637
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$4.65
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$5.10
Rate for Payer: Hawaii Medical Service Association Medicare	$4.65
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$4.65
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$4.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$4.65
Rate for Payer: Ohana Health Plan Medicare	$4.65
Rate for Payer: UnitedHealthcare Medicare	$4.65
Rate for Payer: University Health Alliance Commercial	$10.93

LIDOCAINE 4 % TOPICAL CREAM [23461]

Facility

$15.00

Service Code	NDC 24357070105
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: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

LIDOCAINE 5 % TOPICAL OINTMENT [41831]

Facility

$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

$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 OINTMENT [41831]

Facility

$950.00

Service Code	NDC 64380078932
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 OINTMENT [41831]

Facility

$950.00

Service Code	NDC 68462041820
Hospital Revenue Code	637
Min. Negotiated Rate	$294.50
Max. Negotiated Rate	$921.50
Rate for Payer: AlohaCare Medicaid	$475.00
Rate for Payer: AlohaCare Medicare	$294.50
Rate for Payer: Cash Price	$570.00
Rate for Payer: Devoted Health Medicare	$323.00
Rate for Payer: Hawaii Medical Service Association Medicare	$294.50
Rate for Payer: Hawaii Western Management Group Commercial	$902.50
Rate for Payer: Health Management Network Commercial	$807.50
Rate for Payer: Humana Medicare	$294.50
Rate for Payer: Kaiser Permanente Commercial	$855.00
Rate for Payer: Kaiser Permanente Medicaid	$484.50
Rate for Payer: Kaiser Permanente Medicare	$294.50
Rate for Payer: MDX Hawaii PPO	$921.50
Rate for Payer: Ohana Health Plan Medicaid	$294.50
Rate for Payer: Ohana Health Plan Medicare	$294.50
Rate for Payer: UnitedHealthcare Medicare	$294.50
Rate for Payer: University Health Alliance Commercial	$692.46

LIDOCAINE 5 % TOPICAL OINTMENT [41831]

Facility

$950.00

Service Code	NDC 64380078932
Hospital Revenue Code	637
Min. Negotiated Rate	$294.50
Max. Negotiated Rate	$921.50
Rate for Payer: AlohaCare Medicaid	$475.00
Rate for Payer: AlohaCare Medicare	$294.50
Rate for Payer: Cash Price	$570.00
Rate for Payer: Devoted Health Medicare	$323.00
Rate for Payer: Hawaii Medical Service Association Medicare	$294.50
Rate for Payer: Hawaii Western Management Group Commercial	$902.50
Rate for Payer: Health Management Network Commercial	$807.50
Rate for Payer: Humana Medicare	$294.50
Rate for Payer: Kaiser Permanente Commercial	$855.00
Rate for Payer: Kaiser Permanente Medicaid	$484.50
Rate for Payer: Kaiser Permanente Medicare	$294.50
Rate for Payer: MDX Hawaii PPO	$921.50
Rate for Payer: Ohana Health Plan Medicaid	$294.50
Rate for Payer: Ohana Health Plan Medicare	$294.50
Rate for Payer: UnitedHealthcare Medicare	$294.50
Rate for Payer: University Health Alliance Commercial	$692.46

LIDOCAINE 5 % TOPICAL OINTMENT [41831]

Facility

$905.00

Service Code	NDC 33342040535
Hospital Revenue Code	637
Min. Negotiated Rate	$280.55
Max. Negotiated Rate	$877.85
Rate for Payer: AlohaCare Medicaid	$452.50
Rate for Payer: AlohaCare Medicare	$280.55
Rate for Payer: Cash Price	$543.00
Rate for Payer: Devoted Health Medicare	$307.70
Rate for Payer: Hawaii Medical Service Association Medicare	$280.55
Rate for Payer: Hawaii Western Management Group Commercial	$859.75
Rate for Payer: Health Management Network Commercial	$769.25
Rate for Payer: Humana Medicare	$280.55
Rate for Payer: Kaiser Permanente Commercial	$814.50
Rate for Payer: Kaiser Permanente Medicaid	$461.55
Rate for Payer: Kaiser Permanente Medicare	$280.55
Rate for Payer: MDX Hawaii PPO	$877.85
Rate for Payer: Ohana Health Plan Medicaid	$280.55
Rate for Payer: Ohana Health Plan Medicare	$280.55
Rate for Payer: UnitedHealthcare Medicare	$280.55
Rate for Payer: University Health Alliance Commercial	$659.65

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$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

$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

$80.00

Service Code	NDC 63481068706
Hospital Revenue Code	637
Min. Negotiated Rate	$24.80
Max. Negotiated Rate	$77.60
Rate for Payer: AlohaCare Medicaid	$40.00
Rate for Payer: AlohaCare Medicare	$24.80
Rate for Payer: Cash Price	$48.00
Rate for Payer: Devoted Health Medicare	$27.20
Rate for Payer: Hawaii Medical Service Association Medicare	$24.80
Rate for Payer: Hawaii Western Management Group Commercial	$76.00
Rate for Payer: Health Management Network Commercial	$68.00
Rate for Payer: Humana Medicare	$24.80
Rate for Payer: Kaiser Permanente Commercial	$72.00
Rate for Payer: Kaiser Permanente Medicaid	$40.80
Rate for Payer: Kaiser Permanente Medicare	$24.80
Rate for Payer: MDX Hawaii PPO	$77.60
Rate for Payer: Ohana Health Plan Medicaid	$24.80
Rate for Payer: Ohana Health Plan Medicare	$24.80
Rate for Payer: UnitedHealthcare Medicare	$24.80
Rate for Payer: University Health Alliance Commercial	$58.31

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$84.00

Service Code	NDC 61959000130
Hospital Revenue Code	637
Min. Negotiated Rate	$26.04
Max. Negotiated Rate	$81.48
Rate for Payer: AlohaCare Medicaid	$42.00
Rate for Payer: AlohaCare Medicare	$26.04
Rate for Payer: Cash Price	$50.40
Rate for Payer: Devoted Health Medicare	$28.56
Rate for Payer: Hawaii Medical Service Association Medicare	$26.04
Rate for Payer: Hawaii Western Management Group Commercial	$79.80
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Humana Medicare	$26.04
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: Kaiser Permanente Medicaid	$42.84
Rate for Payer: Kaiser Permanente Medicare	$26.04
Rate for Payer: MDX Hawaii PPO	$81.48
Rate for Payer: Ohana Health Plan Medicaid	$26.04
Rate for Payer: Ohana Health Plan Medicare	$26.04
Rate for Payer: UnitedHealthcare Medicare	$26.04
Rate for Payer: University Health Alliance Commercial	$61.23

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$29.00

Service Code	NDC 00591352530
Hospital Revenue Code	637
Min. Negotiated Rate	$8.99
Max. Negotiated Rate	$28.13
Rate for Payer: AlohaCare Medicaid	$14.50
Rate for Payer: AlohaCare Medicare	$8.99
Rate for Payer: Cash Price	$17.40
Rate for Payer: Devoted Health Medicare	$9.86
Rate for Payer: Hawaii Medical Service Association Medicare	$8.99
Rate for Payer: Hawaii Western Management Group Commercial	$27.55
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Humana Medicare	$8.99
Rate for Payer: Kaiser Permanente Commercial	$26.10
Rate for Payer: Kaiser Permanente Medicaid	$14.79
Rate for Payer: Kaiser Permanente Medicare	$8.99
Rate for Payer: MDX Hawaii PPO	$28.13
Rate for Payer: Ohana Health Plan Medicaid	$8.99
Rate for Payer: Ohana Health Plan Medicare	$8.99
Rate for Payer: UnitedHealthcare Medicare	$8.99
Rate for Payer: University Health Alliance Commercial	$21.14

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$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

Know your out-of-pocket cost for care.

All Charges