Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

lidocaine 4% topical soln [HHSC]

Facility

$218.79

Service Code	NDC 00054350547
Hospital Charge Code	2500484
Hospital Revenue Code	250
Min. Negotiated Rate	$109.39
Max. Negotiated Rate	$212.23
Rate for Payer: AlohaCare Medicaid	$109.39
Rate for Payer: AlohaCare Medicare	$109.39
Rate for Payer: Cash Price	$142.21
Rate for Payer: Devoted Health Medicare	$120.33
Rate for Payer: Hawaii Medical Service Association Medicare	$109.39
Rate for Payer: Hawaii Western Management Group Commercial	$207.85
Rate for Payer: Health Management Network Commercial	$185.97
Rate for Payer: Humana Medicare	$109.39
Rate for Payer: Kaiser Permanente Commercial	$196.91
Rate for Payer: Kaiser Permanente Medicaid	$111.58
Rate for Payer: Kaiser Permanente Medicare	$109.39
Rate for Payer: MDX Hawaii PPO	$212.23
Rate for Payer: Ohana Health Plan Medicaid	$109.39
Rate for Payer: Ohana Health Plan Medicare	$109.39
Rate for Payer: UnitedHealthcare Medicaid	$131.27
Rate for Payer: UnitedHealthcare Medicare	$109.39
Rate for Payer: University Health Alliance Commercial	$159.48

lidocaine 4% topical soln [HHSC]

Facility

$325.38

Service Code	NDC 52565000950
Hospital Charge Code	2500484
Hospital Revenue Code	250
Min. Negotiated Rate	$162.69
Max. Negotiated Rate	$315.62
Rate for Payer: AlohaCare Medicaid	$162.69
Rate for Payer: AlohaCare Medicare	$162.69
Rate for Payer: Cash Price	$211.50
Rate for Payer: Devoted Health Medicare	$178.96
Rate for Payer: Hawaii Medical Service Association Medicare	$162.69
Rate for Payer: Hawaii Western Management Group Commercial	$309.11
Rate for Payer: Health Management Network Commercial	$276.57
Rate for Payer: Humana Medicare	$162.69
Rate for Payer: Kaiser Permanente Commercial	$292.84
Rate for Payer: Kaiser Permanente Medicaid	$165.94
Rate for Payer: Kaiser Permanente Medicare	$162.69
Rate for Payer: MDX Hawaii PPO	$315.62
Rate for Payer: Ohana Health Plan Medicaid	$162.69
Rate for Payer: Ohana Health Plan Medicare	$162.69
Rate for Payer: UnitedHealthcare Medicaid	$195.23
Rate for Payer: UnitedHealthcare Medicare	$162.69
Rate for Payer: University Health Alliance Commercial	$237.17

lidocaine 4% topical soln [HHSC]

Facility

$325.38

Service Code	NDC 00527600480
Hospital Charge Code	2500484
Hospital Revenue Code	250
Min. Negotiated Rate	$162.69
Max. Negotiated Rate	$315.62
Rate for Payer: AlohaCare Medicaid	$162.69
Rate for Payer: AlohaCare Medicare	$162.69
Rate for Payer: Cash Price	$211.50
Rate for Payer: Devoted Health Medicare	$178.96
Rate for Payer: Hawaii Medical Service Association Medicare	$162.69
Rate for Payer: Hawaii Western Management Group Commercial	$309.11
Rate for Payer: Health Management Network Commercial	$276.57
Rate for Payer: Humana Medicare	$162.69
Rate for Payer: Kaiser Permanente Commercial	$292.84
Rate for Payer: Kaiser Permanente Medicaid	$165.94
Rate for Payer: Kaiser Permanente Medicare	$162.69
Rate for Payer: MDX Hawaii PPO	$315.62
Rate for Payer: Ohana Health Plan Medicaid	$162.69
Rate for Payer: Ohana Health Plan Medicare	$162.69
Rate for Payer: UnitedHealthcare Medicaid	$195.23
Rate for Payer: UnitedHealthcare Medicare	$162.69
Rate for Payer: University Health Alliance Commercial	$237.17

lidocaine 4% topical soln [HHSC]

Facility

$218.79

Service Code	NDC 00054350547
Hospital Charge Code	2500484
Hospital Revenue Code	250
Min. Negotiated Rate	$185.97
Max. Negotiated Rate	$212.23
Rate for Payer: Cash Price	$142.21
Rate for Payer: Health Management Network Commercial	$185.97
Rate for Payer: Kaiser Permanente Commercial	$196.91
Rate for Payer: MDX Hawaii PPO	$212.23

lidocaine 4% topical soln [HHSC]

Facility

$325.38

Service Code	NDC 00527600480
Hospital Charge Code	2500484
Hospital Revenue Code	250
Min. Negotiated Rate	$276.57
Max. Negotiated Rate	$315.62
Rate for Payer: Cash Price	$211.50
Rate for Payer: Health Management Network Commercial	$276.57
Rate for Payer: Kaiser Permanente Commercial	$292.84
Rate for Payer: MDX Hawaii PPO	$315.62

lidocaine 5% ointment 35gm [HHSC]

Facility

$895.60

Service Code	NDC 68462041820
Hospital Charge Code	2500486
Hospital Revenue Code	250
Min. Negotiated Rate	$447.80
Max. Negotiated Rate	$868.73
Rate for Payer: AlohaCare Medicaid	$447.80
Rate for Payer: AlohaCare Medicare	$447.80
Rate for Payer: Cash Price	$582.14
Rate for Payer: Devoted Health Medicare	$492.58
Rate for Payer: Hawaii Medical Service Association Medicare	$447.80
Rate for Payer: Hawaii Western Management Group Commercial	$850.82
Rate for Payer: Health Management Network Commercial	$761.26
Rate for Payer: Humana Medicare	$447.80
Rate for Payer: Kaiser Permanente Commercial	$806.04
Rate for Payer: Kaiser Permanente Medicaid	$456.76
Rate for Payer: Kaiser Permanente Medicare	$447.80
Rate for Payer: MDX Hawaii PPO	$868.73
Rate for Payer: Ohana Health Plan Medicaid	$447.80
Rate for Payer: Ohana Health Plan Medicare	$447.80
Rate for Payer: UnitedHealthcare Medicaid	$537.36
Rate for Payer: UnitedHealthcare Medicare	$447.80
Rate for Payer: University Health Alliance Commercial	$652.80

lidocaine 5% ointment 35gm [HHSC]

Facility

$895.60

Service Code	NDC 51672302009
Hospital Charge Code	2500486
Hospital Revenue Code	250
Min. Negotiated Rate	$447.80
Max. Negotiated Rate	$868.73
Rate for Payer: AlohaCare Medicaid	$447.80
Rate for Payer: AlohaCare Medicare	$447.80
Rate for Payer: Cash Price	$582.14
Rate for Payer: Devoted Health Medicare	$492.58
Rate for Payer: Hawaii Medical Service Association Medicare	$447.80
Rate for Payer: Hawaii Western Management Group Commercial	$850.82
Rate for Payer: Health Management Network Commercial	$761.26
Rate for Payer: Humana Medicare	$447.80
Rate for Payer: Kaiser Permanente Commercial	$806.04
Rate for Payer: Kaiser Permanente Medicaid	$456.76
Rate for Payer: Kaiser Permanente Medicare	$447.80
Rate for Payer: MDX Hawaii PPO	$868.73
Rate for Payer: Ohana Health Plan Medicaid	$447.80
Rate for Payer: Ohana Health Plan Medicare	$447.80
Rate for Payer: UnitedHealthcare Medicaid	$537.36
Rate for Payer: UnitedHealthcare Medicare	$447.80
Rate for Payer: University Health Alliance Commercial	$652.80

lidocaine 5% ointment 35gm [HHSC]

Facility

$895.60

Service Code	NDC 68462041820
Hospital Charge Code	2500486
Hospital Revenue Code	250
Min. Negotiated Rate	$761.26
Max. Negotiated Rate	$868.73
Rate for Payer: Cash Price	$582.14
Rate for Payer: Health Management Network Commercial	$761.26
Rate for Payer: Kaiser Permanente Commercial	$806.04
Rate for Payer: MDX Hawaii PPO	$868.73

lidocaine 5% ointment 35gm [HHSC]

Facility

$864.10

Service Code	NDC 33342040535
Hospital Charge Code	2500486
Hospital Revenue Code	250
Min. Negotiated Rate	$432.05
Max. Negotiated Rate	$838.18
Rate for Payer: AlohaCare Medicaid	$432.05
Rate for Payer: AlohaCare Medicare	$432.05
Rate for Payer: Cash Price	$561.67
Rate for Payer: Devoted Health Medicare	$475.25
Rate for Payer: Hawaii Medical Service Association Medicare	$432.05
Rate for Payer: Hawaii Western Management Group Commercial	$820.89
Rate for Payer: Health Management Network Commercial	$734.49
Rate for Payer: Humana Medicare	$432.05
Rate for Payer: Kaiser Permanente Commercial	$777.69
Rate for Payer: Kaiser Permanente Medicaid	$440.69
Rate for Payer: Kaiser Permanente Medicare	$432.05
Rate for Payer: MDX Hawaii PPO	$838.18
Rate for Payer: Ohana Health Plan Medicaid	$432.05
Rate for Payer: Ohana Health Plan Medicare	$432.05
Rate for Payer: UnitedHealthcare Medicaid	$518.46
Rate for Payer: UnitedHealthcare Medicare	$432.05
Rate for Payer: University Health Alliance Commercial	$629.84

lidocaine 5% ointment 35gm [HHSC]

Facility

$861.22

Service Code	NDC 00168020437
Hospital Charge Code	2500486
Hospital Revenue Code	250
Min. Negotiated Rate	$732.04
Max. Negotiated Rate	$835.38
Rate for Payer: Cash Price	$559.79
Rate for Payer: Health Management Network Commercial	$732.04
Rate for Payer: Kaiser Permanente Commercial	$775.10
Rate for Payer: MDX Hawaii PPO	$835.38

lidocaine 5% ointment 35gm [HHSC]

Facility

$864.10

Service Code	NDC 33342040535
Hospital Charge Code	2500486
Hospital Revenue Code	250
Min. Negotiated Rate	$734.49
Max. Negotiated Rate	$838.18
Rate for Payer: Cash Price	$561.67
Rate for Payer: Health Management Network Commercial	$734.49
Rate for Payer: Kaiser Permanente Commercial	$777.69
Rate for Payer: MDX Hawaii PPO	$838.18

lidocaine 5% ointment 35gm [HHSC]

Facility

$895.60

Service Code	NDC 64380078932
Hospital Charge Code	2500486
Hospital Revenue Code	250
Min. Negotiated Rate	$761.26
Max. Negotiated Rate	$868.73
Rate for Payer: Cash Price	$582.14
Rate for Payer: Health Management Network Commercial	$761.26
Rate for Payer: Kaiser Permanente Commercial	$806.04
Rate for Payer: MDX Hawaii PPO	$868.73

lidocaine 5% ointment 35gm [HHSC]

Facility

$895.60

Service Code	NDC 51672302009
Hospital Charge Code	2500486
Hospital Revenue Code	250
Min. Negotiated Rate	$761.26
Max. Negotiated Rate	$868.73
Rate for Payer: Cash Price	$582.14
Rate for Payer: Health Management Network Commercial	$761.26
Rate for Payer: Kaiser Permanente Commercial	$806.04
Rate for Payer: MDX Hawaii PPO	$868.73

lidocaine 5% ointment 35gm [HHSC]

Facility

$895.60

Service Code	NDC 64380078932
Hospital Charge Code	2500486
Hospital Revenue Code	250
Min. Negotiated Rate	$447.80
Max. Negotiated Rate	$868.73
Rate for Payer: AlohaCare Medicaid	$447.80
Rate for Payer: AlohaCare Medicare	$447.80
Rate for Payer: Cash Price	$582.14
Rate for Payer: Devoted Health Medicare	$492.58
Rate for Payer: Hawaii Medical Service Association Medicare	$447.80
Rate for Payer: Hawaii Western Management Group Commercial	$850.82
Rate for Payer: Health Management Network Commercial	$761.26
Rate for Payer: Humana Medicare	$447.80
Rate for Payer: Kaiser Permanente Commercial	$806.04
Rate for Payer: Kaiser Permanente Medicaid	$456.76
Rate for Payer: Kaiser Permanente Medicare	$447.80
Rate for Payer: MDX Hawaii PPO	$868.73
Rate for Payer: Ohana Health Plan Medicaid	$447.80
Rate for Payer: Ohana Health Plan Medicare	$447.80
Rate for Payer: UnitedHealthcare Medicaid	$537.36
Rate for Payer: UnitedHealthcare Medicare	$447.80
Rate for Payer: University Health Alliance Commercial	$652.80

lidocaine 5% ointment 35gm [HHSC]

Facility

$861.22

Service Code	NDC 00168020437
Hospital Charge Code	2500486
Hospital Revenue Code	250
Min. Negotiated Rate	$430.61
Max. Negotiated Rate	$835.38
Rate for Payer: AlohaCare Medicaid	$430.61
Rate for Payer: AlohaCare Medicare	$430.61
Rate for Payer: Cash Price	$559.79
Rate for Payer: Devoted Health Medicare	$473.67
Rate for Payer: Hawaii Medical Service Association Medicare	$430.61
Rate for Payer: Hawaii Western Management Group Commercial	$818.16
Rate for Payer: Health Management Network Commercial	$732.04
Rate for Payer: Humana Medicare	$430.61
Rate for Payer: Kaiser Permanente Commercial	$775.10
Rate for Payer: Kaiser Permanente Medicaid	$439.22
Rate for Payer: Kaiser Permanente Medicare	$430.61
Rate for Payer: MDX Hawaii PPO	$835.38
Rate for Payer: Ohana Health Plan Medicaid	$430.61
Rate for Payer: Ohana Health Plan Medicare	$430.61
Rate for Payer: UnitedHealthcare Medicaid	$516.73
Rate for Payer: UnitedHealthcare Medicare	$430.61
Rate for Payer: University Health Alliance Commercial	$627.74

lidocaine 5% ointment 35gm [HHSC]

Facility

$861.22

Service Code	NDC 65162091838
Hospital Charge Code	2500486
Hospital Revenue Code	250
Min. Negotiated Rate	$732.04
Max. Negotiated Rate	$835.38
Rate for Payer: Cash Price	$559.79
Rate for Payer: Health Management Network Commercial	$732.04
Rate for Payer: Kaiser Permanente Commercial	$775.10
Rate for Payer: MDX Hawaii PPO	$835.38

lidocaine 5% ointment 35gm [HHSC]

Facility

$313.65

Service Code	NDC 69680012035
Hospital Charge Code	2500486
Hospital Revenue Code	250
Min. Negotiated Rate	$156.82
Max. Negotiated Rate	$304.24
Rate for Payer: AlohaCare Medicaid	$156.82
Rate for Payer: AlohaCare Medicare	$156.82
Rate for Payer: Cash Price	$203.87
Rate for Payer: Devoted Health Medicare	$172.51
Rate for Payer: Hawaii Medical Service Association Medicare	$156.82
Rate for Payer: Hawaii Western Management Group Commercial	$297.97
Rate for Payer: Health Management Network Commercial	$266.60
Rate for Payer: Humana Medicare	$156.82
Rate for Payer: Kaiser Permanente Commercial	$282.29
Rate for Payer: Kaiser Permanente Medicaid	$159.96
Rate for Payer: Kaiser Permanente Medicare	$156.82
Rate for Payer: MDX Hawaii PPO	$304.24
Rate for Payer: Ohana Health Plan Medicaid	$156.82
Rate for Payer: Ohana Health Plan Medicare	$156.82
Rate for Payer: UnitedHealthcare Medicaid	$188.19
Rate for Payer: UnitedHealthcare Medicare	$156.82
Rate for Payer: University Health Alliance Commercial	$228.62

lidocaine 5% ointment 35gm [HHSC]

Facility

$313.65

Service Code	NDC 69680012035
Hospital Charge Code	2500486
Hospital Revenue Code	250
Min. Negotiated Rate	$266.60
Max. Negotiated Rate	$304.24
Rate for Payer: Cash Price	$203.87
Rate for Payer: Health Management Network Commercial	$266.60
Rate for Payer: Kaiser Permanente Commercial	$282.29
Rate for Payer: MDX Hawaii PPO	$304.24

lidocaine 5% ointment 35gm [HHSC]

Facility

$861.22

Service Code	NDC 65162091838
Hospital Charge Code	2500486
Hospital Revenue Code	250
Min. Negotiated Rate	$430.61
Max. Negotiated Rate	$835.38
Rate for Payer: AlohaCare Medicaid	$430.61
Rate for Payer: AlohaCare Medicare	$430.61
Rate for Payer: Cash Price	$559.79
Rate for Payer: Devoted Health Medicare	$473.67
Rate for Payer: Hawaii Medical Service Association Medicare	$430.61
Rate for Payer: Hawaii Western Management Group Commercial	$818.16
Rate for Payer: Health Management Network Commercial	$732.04
Rate for Payer: Humana Medicare	$430.61
Rate for Payer: Kaiser Permanente Commercial	$775.10
Rate for Payer: Kaiser Permanente Medicaid	$439.22
Rate for Payer: Kaiser Permanente Medicare	$430.61
Rate for Payer: MDX Hawaii PPO	$835.38
Rate for Payer: Ohana Health Plan Medicaid	$430.61
Rate for Payer: Ohana Health Plan Medicare	$430.61
Rate for Payer: UnitedHealthcare Medicaid	$516.73
Rate for Payer: UnitedHealthcare Medicare	$430.61
Rate for Payer: University Health Alliance Commercial	$627.74

lidocaine 5% ointment 35gm [HHSC]

Facility

$864.10

Service Code	NDC 67877047379
Hospital Charge Code	2500486
Hospital Revenue Code	250
Min. Negotiated Rate	$432.05
Max. Negotiated Rate	$838.18
Rate for Payer: AlohaCare Medicaid	$432.05
Rate for Payer: AlohaCare Medicare	$432.05
Rate for Payer: Cash Price	$561.67
Rate for Payer: Devoted Health Medicare	$475.25
Rate for Payer: Hawaii Medical Service Association Medicare	$432.05
Rate for Payer: Hawaii Western Management Group Commercial	$820.89
Rate for Payer: Health Management Network Commercial	$734.49
Rate for Payer: Humana Medicare	$432.05
Rate for Payer: Kaiser Permanente Commercial	$777.69
Rate for Payer: Kaiser Permanente Medicaid	$440.69
Rate for Payer: Kaiser Permanente Medicare	$432.05
Rate for Payer: MDX Hawaii PPO	$838.18
Rate for Payer: Ohana Health Plan Medicaid	$432.05
Rate for Payer: Ohana Health Plan Medicare	$432.05
Rate for Payer: UnitedHealthcare Medicaid	$518.46
Rate for Payer: UnitedHealthcare Medicare	$432.05
Rate for Payer: University Health Alliance Commercial	$629.84

lidocaine 5% ointment 35gm [HHSC]

Facility

$864.10

Service Code	NDC 67877047379
Hospital Charge Code	2500486
Hospital Revenue Code	250
Min. Negotiated Rate	$734.49
Max. Negotiated Rate	$838.18
Rate for Payer: Cash Price	$561.67
Rate for Payer: Health Management Network Commercial	$734.49
Rate for Payer: Kaiser Permanente Commercial	$777.69
Rate for Payer: MDX Hawaii PPO	$838.18

lidocaine 5% patch [HHSC]

Facility

$19.98

Service Code	NDC 00603188016
Hospital Charge Code	2500485
Hospital Revenue Code	250
Min. Negotiated Rate	$16.98
Max. Negotiated Rate	$19.38
Rate for Payer: Cash Price	$12.99
Rate for Payer: Health Management Network Commercial	$16.98
Rate for Payer: Kaiser Permanente Commercial	$17.98
Rate for Payer: MDX Hawaii PPO	$19.38

lidocaine 5% patch [HHSC]

Facility

$19.02

Service Code	NDC 82347050505
Hospital Charge Code	2500485
Hospital Revenue Code	250
Min. Negotiated Rate	$16.17
Max. Negotiated Rate	$18.45
Rate for Payer: Cash Price	$12.36
Rate for Payer: Health Management Network Commercial	$16.17
Rate for Payer: Kaiser Permanente Commercial	$17.12
Rate for Payer: MDX Hawaii PPO	$18.45

lidocaine 5% patch [HHSC]

Facility

$55.26

Service Code	NDC 00591352530
Hospital Charge Code	2500485
Hospital Revenue Code	250
Min. Negotiated Rate	$27.63
Max. Negotiated Rate	$53.60
Rate for Payer: AlohaCare Medicaid	$27.63
Rate for Payer: AlohaCare Medicare	$27.63
Rate for Payer: Cash Price	$35.92
Rate for Payer: Devoted Health Medicare	$30.39
Rate for Payer: Hawaii Medical Service Association Medicare	$27.63
Rate for Payer: Hawaii Western Management Group Commercial	$52.50
Rate for Payer: Health Management Network Commercial	$46.97
Rate for Payer: Humana Medicare	$27.63
Rate for Payer: Kaiser Permanente Commercial	$49.73
Rate for Payer: Kaiser Permanente Medicaid	$28.18
Rate for Payer: Kaiser Permanente Medicare	$27.63
Rate for Payer: MDX Hawaii PPO	$53.60
Rate for Payer: Ohana Health Plan Medicaid	$27.63
Rate for Payer: Ohana Health Plan Medicare	$27.63
Rate for Payer: UnitedHealthcare Medicaid	$33.16
Rate for Payer: UnitedHealthcare Medicare	$27.63
Rate for Payer: University Health Alliance Commercial	$40.28

lidocaine 5% patch [HHSC]

Facility

$55.26

Service Code	NDC 00591267930
Hospital Charge Code	2500485
Hospital Revenue Code	250
Min. Negotiated Rate	$27.63
Max. Negotiated Rate	$53.60
Rate for Payer: AlohaCare Medicaid	$27.63
Rate for Payer: AlohaCare Medicare	$27.63
Rate for Payer: Cash Price	$35.92
Rate for Payer: Devoted Health Medicare	$30.39
Rate for Payer: Hawaii Medical Service Association Medicare	$27.63
Rate for Payer: Hawaii Western Management Group Commercial	$52.50
Rate for Payer: Health Management Network Commercial	$46.97
Rate for Payer: Humana Medicare	$27.63
Rate for Payer: Kaiser Permanente Commercial	$49.73
Rate for Payer: Kaiser Permanente Medicaid	$28.18
Rate for Payer: Kaiser Permanente Medicare	$27.63
Rate for Payer: MDX Hawaii PPO	$53.60
Rate for Payer: Ohana Health Plan Medicaid	$27.63
Rate for Payer: Ohana Health Plan Medicare	$27.63
Rate for Payer: UnitedHealthcare Medicaid	$33.16
Rate for Payer: UnitedHealthcare Medicare	$27.63
Rate for Payer: University Health Alliance Commercial	$40.28

Know your out-of-pocket cost for care.

All Charges