Kau Hospital

All Charges

Charge

Type

Setting

Price

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

$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	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	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

$29.00

Service Code	NDC 00591267930
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

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

Facility

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

Facility

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

Facility

$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

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

Facility

$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

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

Facility

$17.00

Service Code	HCPCS J2003
Hospital Revenue Code	636
Min. Negotiated Rate	$5.27
Max. Negotiated Rate	$16.49
Rate for Payer: AlohaCare Medicaid	$8.50
Rate for Payer: AlohaCare Medicare	$5.27
Rate for Payer: Cash Price	$10.20
Rate for Payer: Devoted Health Medicare	$5.78
Rate for Payer: Hawaii Medical Service Association Medicare	$5.27
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Humana Medicare	$5.27
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicare	$5.27
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: Ohana Health Plan Medicaid	$5.27
Rate for Payer: Ohana Health Plan Medicare	$5.27
Rate for Payer: UnitedHealthcare Medicaid	$10.20
Rate for Payer: UnitedHealthcare Medicare	$5.27
Rate for Payer: University Health Alliance Commercial	$12.39

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

Facility

$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 2 % MUCOSAL SOLUTION [27898]

Facility

$27.00

Service Code	NDC 00121495015
Hospital Revenue Code	637
Min. Negotiated Rate	$8.37
Max. Negotiated Rate	$26.19
Rate for Payer: AlohaCare Medicaid	$13.50
Rate for Payer: AlohaCare Medicare	$8.37
Rate for Payer: Cash Price	$16.20
Rate for Payer: Devoted Health Medicare	$9.18
Rate for Payer: Hawaii Medical Service Association Medicare	$8.37
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Humana Medicare	$8.37
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: Kaiser Permanente Medicare	$8.37
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: Ohana Health Plan Medicaid	$8.37
Rate for Payer: Ohana Health Plan Medicare	$8.37
Rate for Payer: UnitedHealthcare Medicare	$8.37
Rate for Payer: University Health Alliance Commercial	$19.68

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]

Facility

$27.00

Service Code	NDC 00121495040
Hospital Revenue Code	637
Min. Negotiated Rate	$8.37
Max. Negotiated Rate	$26.19
Rate for Payer: AlohaCare Medicaid	$13.50
Rate for Payer: AlohaCare Medicare	$8.37
Rate for Payer: Cash Price	$16.20
Rate for Payer: Devoted Health Medicare	$9.18
Rate for Payer: Hawaii Medical Service Association Medicare	$8.37
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Humana Medicare	$8.37
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: Kaiser Permanente Medicare	$8.37
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: Ohana Health Plan Medicaid	$8.37
Rate for Payer: Ohana Health Plan Medicare	$8.37
Rate for Payer: UnitedHealthcare Medicare	$8.37
Rate for Payer: University Health Alliance Commercial	$19.68

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]

Facility

$47.00

Service Code	NDC 72888012526
Hospital Revenue Code	637
Min. Negotiated Rate	$14.57
Max. Negotiated Rate	$45.59
Rate for Payer: AlohaCare Medicaid	$23.50
Rate for Payer: AlohaCare Medicare	$14.57
Rate for Payer: Cash Price	$28.20
Rate for Payer: Devoted Health Medicare	$15.98
Rate for Payer: Hawaii Medical Service Association Medicare	$14.57
Rate for Payer: Hawaii Western Management Group Commercial	$44.65
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: Humana Medicare	$14.57
Rate for Payer: Kaiser Permanente Commercial	$42.30
Rate for Payer: Kaiser Permanente Medicaid	$23.97
Rate for Payer: Kaiser Permanente Medicare	$14.57
Rate for Payer: MDX Hawaii PPO	$45.59
Rate for Payer: Ohana Health Plan Medicaid	$14.57
Rate for Payer: Ohana Health Plan Medicare	$14.57
Rate for Payer: UnitedHealthcare Medicare	$14.57
Rate for Payer: University Health Alliance Commercial	$34.26

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]

Facility

$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: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]

Facility

$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

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]

Facility

$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: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19

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

Facility

$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: Kaiser Permanente Commercial	$151.20
Rate for Payer: MDX Hawaii PPO	$162.96

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

Facility

$168.00

Service Code	NDC 00054350547
Hospital Revenue Code	637
Min. Negotiated Rate	$52.08
Max. Negotiated Rate	$162.96
Rate for Payer: AlohaCare Medicaid	$84.00
Rate for Payer: AlohaCare Medicare	$52.08
Rate for Payer: Cash Price	$100.80
Rate for Payer: Devoted Health Medicare	$57.12
Rate for Payer: Hawaii Medical Service Association Medicare	$52.08
Rate for Payer: Hawaii Western Management Group Commercial	$159.60
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Humana Medicare	$52.08
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: Kaiser Permanente Medicaid	$85.68
Rate for Payer: Kaiser Permanente Medicare	$52.08
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: Ohana Health Plan Medicaid	$52.08
Rate for Payer: Ohana Health Plan Medicare	$52.08
Rate for Payer: UnitedHealthcare Medicare	$52.08
Rate for Payer: University Health Alliance Commercial	$122.46

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

Facility

$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: Kaiser Permanente Commercial	$204.30
Rate for Payer: MDX Hawaii PPO	$220.19

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

Facility

$227.00

Service Code	NDC 70954051810
Hospital Revenue Code	637
Min. Negotiated Rate	$70.37
Max. Negotiated Rate	$220.19
Rate for Payer: AlohaCare Medicaid	$113.50
Rate for Payer: AlohaCare Medicare	$70.37
Rate for Payer: Cash Price	$136.20
Rate for Payer: Devoted Health Medicare	$77.18
Rate for Payer: Hawaii Medical Service Association Medicare	$70.37
Rate for Payer: Hawaii Western Management Group Commercial	$215.65
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Humana Medicare	$70.37
Rate for Payer: Kaiser Permanente Commercial	$204.30
Rate for Payer: Kaiser Permanente Medicaid	$115.77
Rate for Payer: Kaiser Permanente Medicare	$70.37
Rate for Payer: MDX Hawaii PPO	$220.19
Rate for Payer: Ohana Health Plan Medicaid	$70.37
Rate for Payer: Ohana Health Plan Medicare	$70.37
Rate for Payer: UnitedHealthcare Medicare	$70.37
Rate for Payer: University Health Alliance Commercial	$165.46

LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION [43717]

Facility

$109.00

Service Code	NDC 76329630005
Hospital Revenue Code	637
Min. Negotiated Rate	$33.79
Max. Negotiated Rate	$105.73
Rate for Payer: AlohaCare Medicaid	$54.50
Rate for Payer: AlohaCare Medicare	$33.79
Rate for Payer: Cash Price	$65.40
Rate for Payer: Devoted Health Medicare	$37.06
Rate for Payer: Hawaii Medical Service Association Medicare	$33.79
Rate for Payer: Hawaii Western Management Group Commercial	$103.55
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Humana Medicare	$33.79
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: Kaiser Permanente Medicaid	$55.59
Rate for Payer: Kaiser Permanente Medicare	$33.79
Rate for Payer: MDX Hawaii PPO	$105.73
Rate for Payer: Ohana Health Plan Medicaid	$33.79
Rate for Payer: Ohana Health Plan Medicare	$33.79
Rate for Payer: UnitedHealthcare Medicare	$33.79
Rate for Payer: University Health Alliance Commercial	$79.45

Know your out-of-pocket cost for care.

All Charges