Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

lidocaine 5% patch [HHSC]

Facility

$139.13

Service Code	NDC 63481068706
Hospital Charge Code	2500485
Hospital Revenue Code	250
Min. Negotiated Rate	$69.56
Max. Negotiated Rate	$134.96
Rate for Payer: AlohaCare Medicaid	$69.56
Rate for Payer: AlohaCare Medicare	$69.56
Rate for Payer: Cash Price	$90.43
Rate for Payer: Devoted Health Medicare	$76.52
Rate for Payer: Hawaii Medical Service Association Medicare	$69.56
Rate for Payer: Hawaii Western Management Group Commercial	$132.17
Rate for Payer: Health Management Network Commercial	$118.26
Rate for Payer: Humana Medicare	$69.56
Rate for Payer: Kaiser Permanente Commercial	$125.22
Rate for Payer: Kaiser Permanente Medicaid	$70.96
Rate for Payer: Kaiser Permanente Medicare	$69.56
Rate for Payer: MDX Hawaii PPO	$134.96
Rate for Payer: Ohana Health Plan Medicaid	$69.56
Rate for Payer: Ohana Health Plan Medicare	$69.56
Rate for Payer: UnitedHealthcare Medicaid	$83.48
Rate for Payer: UnitedHealthcare Medicare	$69.56
Rate for Payer: University Health Alliance Commercial	$101.41

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 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

lidocaine 5% patch [HHSC]

Facility

$59.72

Service Code	NDC 65162079108
Hospital Charge Code	2500485
Hospital Revenue Code	250
Min. Negotiated Rate	$50.76
Max. Negotiated Rate	$57.93
Rate for Payer: Cash Price	$38.82
Rate for Payer: Health Management Network Commercial	$50.76
Rate for Payer: Kaiser Permanente Commercial	$53.75
Rate for Payer: MDX Hawaii PPO	$57.93

lidocaine 5% patch [HHSC]

Facility

$55.26

Service Code	NDC 00591352530
Hospital Charge Code	2500485
Hospital Revenue Code	250
Min. Negotiated Rate	$46.97
Max. Negotiated Rate	$53.60
Rate for Payer: Cash Price	$35.92
Rate for Payer: Health Management Network Commercial	$46.97
Rate for Payer: Kaiser Permanente Commercial	$49.73
Rate for Payer: MDX Hawaii PPO	$53.60

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

$19.98

Service Code	NDC 00603188016
Hospital Charge Code	2500485
Hospital Revenue Code	250
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$19.38
Rate for Payer: AlohaCare Medicaid	$9.99
Rate for Payer: AlohaCare Medicare	$9.99
Rate for Payer: Cash Price	$12.99
Rate for Payer: Devoted Health Medicare	$10.99
Rate for Payer: Hawaii Medical Service Association Medicare	$9.99
Rate for Payer: Hawaii Western Management Group Commercial	$18.98
Rate for Payer: Health Management Network Commercial	$16.98
Rate for Payer: Humana Medicare	$9.99
Rate for Payer: Kaiser Permanente Commercial	$17.98
Rate for Payer: Kaiser Permanente Medicaid	$10.19
Rate for Payer: Kaiser Permanente Medicare	$9.99
Rate for Payer: MDX Hawaii PPO	$19.38
Rate for Payer: Ohana Health Plan Medicaid	$9.99
Rate for Payer: Ohana Health Plan Medicare	$9.99
Rate for Payer: UnitedHealthcare Medicaid	$11.99
Rate for Payer: UnitedHealthcare Medicare	$9.99
Rate for Payer: University Health Alliance Commercial	$14.56

lidocaine 5% patch [HHSC]

Facility

$59.72

Service Code	NDC 00378905593
Hospital Charge Code	2500485
Hospital Revenue Code	250
Min. Negotiated Rate	$50.76
Max. Negotiated Rate	$57.93
Rate for Payer: Cash Price	$38.82
Rate for Payer: Health Management Network Commercial	$50.76
Rate for Payer: Kaiser Permanente Commercial	$53.75
Rate for Payer: MDX Hawaii PPO	$57.93

lidocaine 5% patch [HHSC]

Facility

$59.72

Service Code	NDC 00378905593
Hospital Charge Code	2500485
Hospital Revenue Code	250
Min. Negotiated Rate	$29.86
Max. Negotiated Rate	$57.93
Rate for Payer: AlohaCare Medicaid	$29.86
Rate for Payer: AlohaCare Medicare	$29.86
Rate for Payer: Cash Price	$38.82
Rate for Payer: Devoted Health Medicare	$32.85
Rate for Payer: Hawaii Medical Service Association Medicare	$29.86
Rate for Payer: Hawaii Western Management Group Commercial	$56.73
Rate for Payer: Health Management Network Commercial	$50.76
Rate for Payer: Humana Medicare	$29.86
Rate for Payer: Kaiser Permanente Commercial	$53.75
Rate for Payer: Kaiser Permanente Medicaid	$30.46
Rate for Payer: Kaiser Permanente Medicare	$29.86
Rate for Payer: MDX Hawaii PPO	$57.93
Rate for Payer: Ohana Health Plan Medicaid	$29.86
Rate for Payer: Ohana Health Plan Medicare	$29.86
Rate for Payer: UnitedHealthcare Medicaid	$35.83
Rate for Payer: UnitedHealthcare Medicare	$29.86
Rate for Payer: University Health Alliance Commercial	$43.53

lidocaine 5% patch [HHSC]

Facility

$151.11

Service Code	NDC 61959000130
Hospital Charge Code	2500485
Hospital Revenue Code	250
Min. Negotiated Rate	$75.56
Max. Negotiated Rate	$146.58
Rate for Payer: AlohaCare Medicaid	$75.56
Rate for Payer: AlohaCare Medicare	$75.56
Rate for Payer: Cash Price	$98.22
Rate for Payer: Devoted Health Medicare	$83.11
Rate for Payer: Hawaii Medical Service Association Medicare	$75.56
Rate for Payer: Hawaii Western Management Group Commercial	$143.55
Rate for Payer: Health Management Network Commercial	$128.44
Rate for Payer: Humana Medicare	$75.56
Rate for Payer: Kaiser Permanente Commercial	$136.00
Rate for Payer: Kaiser Permanente Medicaid	$77.07
Rate for Payer: Kaiser Permanente Medicare	$75.56
Rate for Payer: MDX Hawaii PPO	$146.58
Rate for Payer: Ohana Health Plan Medicaid	$75.56
Rate for Payer: Ohana Health Plan Medicare	$75.56
Rate for Payer: UnitedHealthcare Medicaid	$90.67
Rate for Payer: UnitedHealthcare Medicare	$75.56
Rate for Payer: University Health Alliance Commercial	$110.14

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

$151.11

Service Code	NDC 61959000130
Hospital Charge Code	2500485
Hospital Revenue Code	250
Min. Negotiated Rate	$128.44
Max. Negotiated Rate	$146.58
Rate for Payer: Cash Price	$98.22
Rate for Payer: Health Management Network Commercial	$128.44
Rate for Payer: Kaiser Permanente Commercial	$136.00
Rate for Payer: MDX Hawaii PPO	$146.58

lidocaine-D5W 2000 mg/500 mL premix [HHSC]

Facility

$49.42

Service Code	HCPCS J2002
Hospital Charge Code	2501181
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$47.94
Rate for Payer: AlohaCare Medicaid	$24.71
Rate for Payer: AlohaCare Medicare	$24.71
Rate for Payer: Cash Price	$32.12
Rate for Payer: Cash Price	$32.12
Rate for Payer: Devoted Health Medicare	$27.18
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Medicare	$24.71
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$46.95
Rate for Payer: Health Management Network Commercial	$42.01
Rate for Payer: Humana Medicare	$24.71
Rate for Payer: Kaiser Permanente Commercial	$44.48
Rate for Payer: Kaiser Permanente Medicaid	$25.20
Rate for Payer: Kaiser Permanente Medicare	$24.71
Rate for Payer: MDX Hawaii PPO	$47.94
Rate for Payer: Ohana Health Plan Medicaid	$24.71
Rate for Payer: Ohana Health Plan Medicare	$24.71
Rate for Payer: UnitedHealthcare Medicaid	$29.65
Rate for Payer: UnitedHealthcare Medicare	$24.71
Rate for Payer: University Health Alliance Commercial	$36.02

lidocaine-D5W 2000 mg/500 mL premix [HHSC]

Facility

$49.42

Service Code	HCPCS J2002
Hospital Charge Code	2501181
Hospital Revenue Code	250
Min. Negotiated Rate	$42.01
Max. Negotiated Rate	$47.94
Rate for Payer: Cash Price	$32.12
Rate for Payer: Health Management Network Commercial	$42.01
Rate for Payer: Kaiser Permanente Commercial	$44.48
Rate for Payer: MDX Hawaii PPO	$47.94

lidocaine-viscous 2% 15 mL [HHSC]

Facility

$6.00

Service Code	NDC 50383077517
Hospital Charge Code	2500483
Hospital Revenue Code	250
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$3.00
Rate for Payer: Cash Price	$3.90
Rate for Payer: Devoted Health Medicare	$3.30
Rate for Payer: Hawaii Medical Service Association Medicare	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$3.00
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$3.00
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$3.00
Rate for Payer: Ohana Health Plan Medicare	$3.00
Rate for Payer: UnitedHealthcare Medicaid	$3.60
Rate for Payer: UnitedHealthcare Medicare	$3.00
Rate for Payer: University Health Alliance Commercial	$4.37

lidocaine-viscous 2% 15 mL [HHSC]

Facility

$42.44

Service Code	NDC 00121495040
Hospital Charge Code	2500483
Hospital Revenue Code	250
Min. Negotiated Rate	$21.22
Max. Negotiated Rate	$41.17
Rate for Payer: AlohaCare Medicaid	$21.22
Rate for Payer: AlohaCare Medicare	$21.22
Rate for Payer: Cash Price	$27.59
Rate for Payer: Devoted Health Medicare	$23.34
Rate for Payer: Hawaii Medical Service Association Medicare	$21.22
Rate for Payer: Hawaii Western Management Group Commercial	$40.32
Rate for Payer: Health Management Network Commercial	$36.07
Rate for Payer: Humana Medicare	$21.22
Rate for Payer: Kaiser Permanente Commercial	$38.20
Rate for Payer: Kaiser Permanente Medicaid	$21.64
Rate for Payer: Kaiser Permanente Medicare	$21.22
Rate for Payer: MDX Hawaii PPO	$41.17
Rate for Payer: Ohana Health Plan Medicaid	$21.22
Rate for Payer: Ohana Health Plan Medicare	$21.22
Rate for Payer: UnitedHealthcare Medicaid	$25.46
Rate for Payer: UnitedHealthcare Medicare	$21.22
Rate for Payer: University Health Alliance Commercial	$30.93

lidocaine-viscous 2% 15 mL [HHSC]

Facility

$13.09

Service Code	NDC 00121090340
Hospital Charge Code	2500483
Hospital Revenue Code	250
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$12.70
Rate for Payer: AlohaCare Medicaid	$6.54
Rate for Payer: AlohaCare Medicare	$6.54
Rate for Payer: Cash Price	$8.51
Rate for Payer: Devoted Health Medicare	$7.20
Rate for Payer: Hawaii Medical Service Association Medicare	$6.54
Rate for Payer: Hawaii Western Management Group Commercial	$12.44
Rate for Payer: Health Management Network Commercial	$11.13
Rate for Payer: Humana Medicare	$6.54
Rate for Payer: Kaiser Permanente Commercial	$11.78
Rate for Payer: Kaiser Permanente Medicaid	$6.68
Rate for Payer: Kaiser Permanente Medicare	$6.54
Rate for Payer: MDX Hawaii PPO	$12.70
Rate for Payer: Ohana Health Plan Medicaid	$6.54
Rate for Payer: Ohana Health Plan Medicare	$6.54
Rate for Payer: UnitedHealthcare Medicaid	$7.85
Rate for Payer: UnitedHealthcare Medicare	$6.54
Rate for Payer: University Health Alliance Commercial	$9.54

lidocaine-viscous 2% 15 mL [HHSC]

Facility

$42.44

Service Code	NDC 00121495040
Hospital Charge Code	2500483
Hospital Revenue Code	250
Min. Negotiated Rate	$36.07
Max. Negotiated Rate	$41.17
Rate for Payer: Cash Price	$27.59
Rate for Payer: Health Management Network Commercial	$36.07
Rate for Payer: Kaiser Permanente Commercial	$38.20
Rate for Payer: MDX Hawaii PPO	$41.17

lidocaine-viscous 2% 15 mL [HHSC]

Facility

$6.00

Service Code	NDC 50383077517
Hospital Charge Code	2500483
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

lidocaine-viscous 2% 15 mL [HHSC]

Facility

$13.09

Service Code	NDC 00121090340
Hospital Charge Code	2500483
Hospital Revenue Code	250
Min. Negotiated Rate	$11.13
Max. Negotiated Rate	$12.70
Rate for Payer: Cash Price	$8.51
Rate for Payer: Health Management Network Commercial	$11.13
Rate for Payer: Kaiser Permanente Commercial	$11.78
Rate for Payer: MDX Hawaii PPO	$12.70

lidocaine-viscous 2% 15 mL [HHSC]

Facility

$6.00

Service Code	NDC 50383036317
Hospital Charge Code	2500483
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

lidocaine-viscous 2% 15 mL [HHSC]

Facility

$11.47

Service Code	NDC 00054350049
Hospital Charge Code	2500483
Hospital Revenue Code	250
Min. Negotiated Rate	$5.74
Max. Negotiated Rate	$11.13
Rate for Payer: AlohaCare Medicaid	$5.74
Rate for Payer: AlohaCare Medicare	$5.74
Rate for Payer: Cash Price	$7.46
Rate for Payer: Devoted Health Medicare	$6.31
Rate for Payer: Hawaii Medical Service Association Medicare	$5.74
Rate for Payer: Hawaii Western Management Group Commercial	$10.90
Rate for Payer: Health Management Network Commercial	$9.75
Rate for Payer: Humana Medicare	$5.74
Rate for Payer: Kaiser Permanente Commercial	$10.32
Rate for Payer: Kaiser Permanente Medicaid	$5.85
Rate for Payer: Kaiser Permanente Medicare	$5.74
Rate for Payer: MDX Hawaii PPO	$11.13
Rate for Payer: Ohana Health Plan Medicaid	$5.74
Rate for Payer: Ohana Health Plan Medicare	$5.74
Rate for Payer: UnitedHealthcare Medicaid	$6.88
Rate for Payer: UnitedHealthcare Medicare	$5.74
Rate for Payer: University Health Alliance Commercial	$8.36

lidocaine-viscous 2% 15 mL [HHSC]

Facility

$11.47

Service Code	NDC 00054350049
Hospital Charge Code	2500483
Hospital Revenue Code	250
Min. Negotiated Rate	$9.75
Max. Negotiated Rate	$11.13
Rate for Payer: Cash Price	$7.46
Rate for Payer: Health Management Network Commercial	$9.75
Rate for Payer: Kaiser Permanente Commercial	$10.32
Rate for Payer: MDX Hawaii PPO	$11.13

lidocaine-viscous 2% 15 mL [HHSC]

Facility

$6.00

Service Code	NDC 50383036317
Hospital Charge Code	2500483
Hospital Revenue Code	250
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$3.00
Rate for Payer: Cash Price	$3.90
Rate for Payer: Devoted Health Medicare	$3.30
Rate for Payer: Hawaii Medical Service Association Medicare	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$3.00
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$3.00
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$3.00
Rate for Payer: Ohana Health Plan Medicare	$3.00
Rate for Payer: UnitedHealthcare Medicaid	$3.60
Rate for Payer: UnitedHealthcare Medicare	$3.00
Rate for Payer: University Health Alliance Commercial	$4.37

lidocaine-viscous 2% 15 mL [HHSC]

Facility

$91.89

Service Code	NDC 62135071242
Hospital Charge Code	2500483
Hospital Revenue Code	250
Min. Negotiated Rate	$78.11
Max. Negotiated Rate	$89.13
Rate for Payer: Cash Price	$59.73
Rate for Payer: Health Management Network Commercial	$78.11
Rate for Payer: Kaiser Permanente Commercial	$82.70
Rate for Payer: MDX Hawaii PPO	$89.13

Know your out-of-pocket cost for care.

All Charges