Kona Community Hospital

All Charges

Charge

Type

Setting

Price

LIDOCAINE HCL 2 % MM SOLN

Facility

$91.03

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$77.38
Max. Negotiated Rate	$88.30
Rate for Payer: Cash Price	$59.17
Rate for Payer: Cash Price	$30.43
Rate for Payer: Health Management Network Commercial	$39.80
Rate for Payer: Health Management Network Commercial	$77.38
Rate for Payer: MDX Hawaii PPO	$88.30
Rate for Payer: MDX Hawaii PPO	$45.42

LIDOCAINE HCL 4 % MM SOLN

Facility

$18.22

Service Code	NDC RPKWH000693
Hospital Revenue Code	250
Min. Negotiated Rate	$15.49
Max. Negotiated Rate	$17.67
Rate for Payer: Cash Price	$11.84
Rate for Payer: Health Management Network Commercial	$15.49
Rate for Payer: MDX Hawaii PPO	$17.67

LIDOCAINE HCL 4 % MM SOLN

Facility

$18.22

Service Code	NDC RPKWH000693
Hospital Revenue Code	250
Min. Negotiated Rate	$9.29
Max. Negotiated Rate	$17.67
Rate for Payer: Cash Price	$11.84
Rate for Payer: Hawaii Western Management Group Commercial	$17.31
Rate for Payer: Health Management Network Commercial	$15.49
Rate for Payer: Kaiser Permanente Commercial	$11.48
Rate for Payer: Kaiser Permanente Medicaid	$9.29
Rate for Payer: MDX Hawaii PPO	$17.67
Rate for Payer: UnitedHealthcare Medicaid	$10.93
Rate for Payer: University Health Alliance Commercial	$13.28

LIDOCAINE HCL (PF) 1 % (10 MG/ML) INJ SOLN

Facility

$7.09

Service Code	NDC 00409471342
Hospital Revenue Code	250
Min. Negotiated Rate	$3.62
Max. Negotiated Rate	$6.88
Rate for Payer: Cash Price	$4.61
Rate for Payer: Hawaii Western Management Group Commercial	$6.74
Rate for Payer: Health Management Network Commercial	$6.03
Rate for Payer: Kaiser Permanente Commercial	$4.47
Rate for Payer: Kaiser Permanente Medicaid	$3.62
Rate for Payer: MDX Hawaii PPO	$6.88
Rate for Payer: UnitedHealthcare Medicaid	$4.25
Rate for Payer: University Health Alliance Commercial	$5.17

LIDOCAINE HCL (PF) 1 % (10 MG/ML) INJ SOLN

Facility

$7.09

Service Code	NDC 00409471325
Hospital Revenue Code	250
Min. Negotiated Rate	$6.03
Max. Negotiated Rate	$6.88
Rate for Payer: Cash Price	$4.61
Rate for Payer: Health Management Network Commercial	$6.03
Rate for Payer: MDX Hawaii PPO	$6.88

LIDOCAINE HCL (PF) 1 % (10 MG/ML) INJ SOLN

Facility

$7.09

Service Code	NDC 00409471325
Hospital Revenue Code	250
Min. Negotiated Rate	$3.62
Max. Negotiated Rate	$6.88
Rate for Payer: Cash Price	$4.61
Rate for Payer: Hawaii Western Management Group Commercial	$6.74
Rate for Payer: Health Management Network Commercial	$6.03
Rate for Payer: Kaiser Permanente Commercial	$4.47
Rate for Payer: Kaiser Permanente Medicaid	$3.62
Rate for Payer: MDX Hawaii PPO	$6.88
Rate for Payer: UnitedHealthcare Medicaid	$4.25
Rate for Payer: University Health Alliance Commercial	$5.17

LIDOCAINE HCL (PF) 1 % (10 MG/ML) INJ SOLN

Facility

$7.09

Service Code	NDC 00409471342
Hospital Revenue Code	250
Min. Negotiated Rate	$6.03
Max. Negotiated Rate	$6.88
Rate for Payer: Cash Price	$4.61
Rate for Payer: Health Management Network Commercial	$6.03
Rate for Payer: MDX Hawaii PPO	$6.88

LIDOCAINE HCL (PF) 1 % (10 MG/ML) INJ SOLN (5 ML)

Facility

$21.70

Service Code	NDC 63323049209
Hospital Revenue Code	250
Min. Negotiated Rate	$18.45
Max. Negotiated Rate	$21.05
Rate for Payer: Cash Price	$14.10
Rate for Payer: Health Management Network Commercial	$18.45
Rate for Payer: MDX Hawaii PPO	$21.05

LIDOCAINE HCL (PF) 1 % (10 MG/ML) INJ SOLN (5 ML)

Facility

$22.36

Service Code	NDC 55150016205
Hospital Revenue Code	250
Min. Negotiated Rate	$11.40
Max. Negotiated Rate	$21.69
Rate for Payer: Cash Price	$14.53
Rate for Payer: Hawaii Western Management Group Commercial	$21.24
Rate for Payer: Health Management Network Commercial	$19.01
Rate for Payer: Kaiser Permanente Commercial	$14.09
Rate for Payer: Kaiser Permanente Medicaid	$11.40
Rate for Payer: MDX Hawaii PPO	$21.69
Rate for Payer: UnitedHealthcare Medicaid	$13.42
Rate for Payer: University Health Alliance Commercial	$16.30

LIDOCAINE HCL (PF) 1 % (10 MG/ML) INJ SOLN (5 ML)

Facility

$21.70

Service Code	NDC 63323049209
Hospital Revenue Code	250
Min. Negotiated Rate	$11.07
Max. Negotiated Rate	$21.05
Rate for Payer: Cash Price	$14.10
Rate for Payer: Hawaii Western Management Group Commercial	$20.61
Rate for Payer: Health Management Network Commercial	$18.45
Rate for Payer: Kaiser Permanente Commercial	$13.67
Rate for Payer: Kaiser Permanente Medicaid	$11.07
Rate for Payer: MDX Hawaii PPO	$21.05
Rate for Payer: UnitedHealthcare Medicaid	$13.02
Rate for Payer: University Health Alliance Commercial	$15.82

LIDOCAINE HCL (PF) 1 % (10 MG/ML) INJ SOLN (5 ML)

Facility

$22.36

Service Code	NDC 55150016205
Hospital Revenue Code	250
Min. Negotiated Rate	$19.01
Max. Negotiated Rate	$21.69
Rate for Payer: Cash Price	$14.53
Rate for Payer: Health Management Network Commercial	$19.01
Rate for Payer: MDX Hawaii PPO	$21.69

LIDOCAINE HCL (PF) 1 % (10 MG/ML) INJ SOLN (5 ML)

Facility

$21.70

Service Code	NDC 63323049257
Hospital Revenue Code	250
Min. Negotiated Rate	$18.45
Max. Negotiated Rate	$21.05
Rate for Payer: Cash Price	$14.10
Rate for Payer: Health Management Network Commercial	$18.45
Rate for Payer: MDX Hawaii PPO	$21.05

LIDOCAINE HCL (PF) 1 % (10 MG/ML) INJ SOLN (5 ML)

Facility

$21.70

Service Code	NDC 63323049257
Hospital Revenue Code	250
Min. Negotiated Rate	$11.07
Max. Negotiated Rate	$21.05
Rate for Payer: Cash Price	$14.10
Rate for Payer: Hawaii Western Management Group Commercial	$20.61
Rate for Payer: Health Management Network Commercial	$18.45
Rate for Payer: Kaiser Permanente Commercial	$13.67
Rate for Payer: Kaiser Permanente Medicaid	$11.07
Rate for Payer: MDX Hawaii PPO	$21.05
Rate for Payer: UnitedHealthcare Medicaid	$13.02
Rate for Payer: University Health Alliance Commercial	$15.82

LIDOCAINE HCL (PF) 2% (20 MG/ML) INJ SOLN

Facility

$44.57

Service Code	NDC 00409428212
Hospital Revenue Code	250
Min. Negotiated Rate	$22.73
Max. Negotiated Rate	$43.23
Rate for Payer: Cash Price	$28.97
Rate for Payer: Hawaii Western Management Group Commercial	$42.34
Rate for Payer: Health Management Network Commercial	$37.88
Rate for Payer: Kaiser Permanente Commercial	$28.08
Rate for Payer: Kaiser Permanente Medicaid	$22.73
Rate for Payer: MDX Hawaii PPO	$43.23
Rate for Payer: UnitedHealthcare Medicaid	$26.74
Rate for Payer: University Health Alliance Commercial	$32.49

LIDOCAINE HCL (PF) 2% (20 MG/ML) INJ SOLN

Facility

$44.57

Service Code	NDC 00409428202
Hospital Revenue Code	250
Min. Negotiated Rate	$37.88
Max. Negotiated Rate	$43.23
Rate for Payer: Cash Price	$28.97
Rate for Payer: Health Management Network Commercial	$37.88
Rate for Payer: MDX Hawaii PPO	$43.23

LIDOCAINE HCL (PF) 2% (20 MG/ML) INJ SOLN

Facility

$44.57

Service Code	NDC 00409428212
Hospital Revenue Code	250
Min. Negotiated Rate	$37.88
Max. Negotiated Rate	$43.23
Rate for Payer: Cash Price	$28.97
Rate for Payer: Health Management Network Commercial	$37.88
Rate for Payer: MDX Hawaii PPO	$43.23

LIDOCAINE HCL (PF) 2% (20 MG/ML) INJ SOLN

Facility

$44.57

Service Code	NDC 00409428202
Hospital Revenue Code	250
Min. Negotiated Rate	$22.73
Max. Negotiated Rate	$43.23
Rate for Payer: Cash Price	$28.97
Rate for Payer: Hawaii Western Management Group Commercial	$42.34
Rate for Payer: Health Management Network Commercial	$37.88
Rate for Payer: Kaiser Permanente Commercial	$28.08
Rate for Payer: Kaiser Permanente Medicaid	$22.73
Rate for Payer: MDX Hawaii PPO	$43.23
Rate for Payer: UnitedHealthcare Medicaid	$26.74
Rate for Payer: University Health Alliance Commercial	$32.49

LIDOCAINE HCL (PF) 2% (20 MG/ML) INJ SOLN

Facility

$11.77

Service Code	NDC 00409428201
Hospital Revenue Code	250
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.42
Rate for Payer: Cash Price	$7.65
Rate for Payer: Hawaii Western Management Group Commercial	$11.18
Rate for Payer: Health Management Network Commercial	$10.00
Rate for Payer: Kaiser Permanente Commercial	$7.42
Rate for Payer: Kaiser Permanente Medicaid	$6.00
Rate for Payer: MDX Hawaii PPO	$11.42
Rate for Payer: UnitedHealthcare Medicaid	$7.06
Rate for Payer: University Health Alliance Commercial	$8.58

LIDOCAINE HCL (PF) 2% (20 MG/ML) INJ SOLN

Facility

$11.77

Service Code	NDC 00409428211
Hospital Revenue Code	250
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$11.42
Rate for Payer: Cash Price	$7.65
Rate for Payer: Health Management Network Commercial	$10.00
Rate for Payer: MDX Hawaii PPO	$11.42

LIDOCAINE HCL (PF) 2% (20 MG/ML) INJ SOLN

Facility

$11.77

Service Code	NDC 00409428211
Hospital Revenue Code	250
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.42
Rate for Payer: Cash Price	$7.65
Rate for Payer: Hawaii Western Management Group Commercial	$11.18
Rate for Payer: Health Management Network Commercial	$10.00
Rate for Payer: Kaiser Permanente Commercial	$7.42
Rate for Payer: Kaiser Permanente Medicaid	$6.00
Rate for Payer: MDX Hawaii PPO	$11.42
Rate for Payer: UnitedHealthcare Medicaid	$7.06
Rate for Payer: University Health Alliance Commercial	$8.58

LIDOCAINE HCL (PF) 2% (20 MG/ML) INJ SOLN

Facility

$11.77

Service Code	NDC 00409428201
Hospital Revenue Code	250
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$11.42
Rate for Payer: Cash Price	$7.65
Rate for Payer: Health Management Network Commercial	$10.00
Rate for Payer: MDX Hawaii PPO	$11.42

LIDOCAINE IN 5 % DEXTROSE (PF) 4 MG/ML (0.4 %) IV SOLP

Facility

$48.29

Service Code	HCPCS J2002
Hospital Revenue Code	250
Min. Negotiated Rate	$41.05
Max. Negotiated Rate	$46.84
Rate for Payer: Cash Price	$31.39
Rate for Payer: Cash Price	$34.53
Rate for Payer: Health Management Network Commercial	$45.16
Rate for Payer: Health Management Network Commercial	$41.05
Rate for Payer: MDX Hawaii PPO	$51.54
Rate for Payer: MDX Hawaii PPO	$46.84

LIDOCAINE IN 5 % DEXTROSE (PF) 4 MG/ML (0.4 %) IV SOLP

Facility

$53.13

Service Code	HCPCS J2002
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$51.54
Rate for Payer: Cash Price	$34.53
Rate for Payer: Cash Price	$31.39
Rate for Payer: Cash Price	$31.39
Rate for Payer: Cash Price	$34.53
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$45.88
Rate for Payer: Hawaii Western Management Group Commercial	$50.47
Rate for Payer: Health Management Network Commercial	$45.16
Rate for Payer: Health Management Network Commercial	$41.05
Rate for Payer: Kaiser Permanente Commercial	$33.47
Rate for Payer: Kaiser Permanente Commercial	$30.42
Rate for Payer: Kaiser Permanente Medicaid	$24.63
Rate for Payer: Kaiser Permanente Medicaid	$27.10
Rate for Payer: MDX Hawaii PPO	$46.84
Rate for Payer: MDX Hawaii PPO	$51.54
Rate for Payer: UnitedHealthcare Medicaid	$28.97
Rate for Payer: UnitedHealthcare Medicaid	$31.88
Rate for Payer: University Health Alliance Commercial	$35.20
Rate for Payer: University Health Alliance Commercial	$38.73

LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYR

Facility

$52.94

Service Code	NDC 76329339001
Hospital Revenue Code	250
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$51.35
Rate for Payer: Cash Price	$34.41
Rate for Payer: Health Management Network Commercial	$45.00
Rate for Payer: MDX Hawaii PPO	$51.35

LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYR

Facility

$52.94

Service Code	NDC 76329339001
Hospital Revenue Code	250
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$51.35
Rate for Payer: Cash Price	$34.41
Rate for Payer: Hawaii Western Management Group Commercial	$50.29
Rate for Payer: Health Management Network Commercial	$45.00
Rate for Payer: Kaiser Permanente Commercial	$33.35
Rate for Payer: Kaiser Permanente Medicaid	$27.00
Rate for Payer: MDX Hawaii PPO	$51.35
Rate for Payer: UnitedHealthcare Medicaid	$31.76
Rate for Payer: University Health Alliance Commercial	$38.59

Know your out-of-pocket cost for care.

All Charges