|
LEVOTHYROXINE 88 MCG TABLET [10403]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687048611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
LEVOTHYROXINE 88 MCG TABLET [10403]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687048601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
LEVOTHYROXINE 88 MCG TABLET [10403]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 42292003820
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
LFIT V40 FEMORAL HD 6260-9-128
|
Facility
|
OP
|
$1,971.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,005.21 |
| Max. Negotiated Rate |
$1,911.87 |
| Rate for Payer: Cash Price |
$1,182.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,379.70
|
| Rate for Payer: Health Management Network Commercial |
$1,675.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,241.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,005.21
|
| Rate for Payer: MDX Hawaii PPO |
$1,911.87
|
| Rate for Payer: University Health Alliance Commercial |
$1,103.76
|
|
|
LFIT V40 FEMORAL HD 6260-9-128
|
Facility
|
IP
|
$1,971.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,103.76 |
| Max. Negotiated Rate |
$1,911.87 |
| Rate for Payer: Cash Price |
$1,182.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,379.70
|
| Rate for Payer: Health Management Network Commercial |
$1,675.35
|
| Rate for Payer: MDX Hawaii PPO |
$1,911.87
|
| Rate for Payer: University Health Alliance Commercial |
$1,103.76
|
|
|
LFITV40 FH 22.2MM 6260-9-122
|
Facility
|
OP
|
$1,990.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,014.90 |
| Max. Negotiated Rate |
$1,930.30 |
| Rate for Payer: Cash Price |
$1,194.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,393.00
|
| Rate for Payer: Health Management Network Commercial |
$1,691.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,253.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,014.90
|
| Rate for Payer: MDX Hawaii PPO |
$1,930.30
|
| Rate for Payer: University Health Alliance Commercial |
$1,114.40
|
|
|
LFITV40 FH 22.2MM 6260-9-122
|
Facility
|
IP
|
$1,990.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,114.40 |
| Max. Negotiated Rate |
$1,930.30 |
| Rate for Payer: Cash Price |
$1,194.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,393.00
|
| Rate for Payer: Health Management Network Commercial |
$1,691.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,930.30
|
| Rate for Payer: University Health Alliance Commercial |
$1,114.40
|
|
|
LG KNEE CRYO CUFF ONLY 11B01
|
Facility
|
OP
|
$167.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$85.17 |
| Max. Negotiated Rate |
$161.99 |
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$158.65
|
| Rate for Payer: Health Management Network Commercial |
$141.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.17
|
| Rate for Payer: MDX Hawaii PPO |
$161.99
|
| Rate for Payer: University Health Alliance Commercial |
$121.73
|
|
|
LG KNEE CRYO CUFF ONLY 11B01
|
Facility
|
IP
|
$167.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$141.95 |
| Max. Negotiated Rate |
$161.99 |
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Health Management Network Commercial |
$141.95
|
| Rate for Payer: MDX Hawaii PPO |
$161.99
|
|
|
L HOOK ELECTRODE E3773-36C
|
Facility
|
IP
|
$174.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$147.90 |
| Max. Negotiated Rate |
$168.78 |
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Health Management Network Commercial |
$147.90
|
| Rate for Payer: MDX Hawaii PPO |
$168.78
|
|
|
L HOOK ELECTRODE E3773-36C
|
Facility
|
OP
|
$174.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$88.74 |
| Max. Negotiated Rate |
$168.78 |
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$165.30
|
| Rate for Payer: Health Management Network Commercial |
$147.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$109.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.74
|
| Rate for Payer: MDX Hawaii PPO |
$168.78
|
| Rate for Payer: University Health Alliance Commercial |
$126.83
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
NDC 63323048205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.75 |
| Max. Negotiated Rate |
$53.35 |
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
NDC 63323048257
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.75 |
| Max. Negotiated Rate |
$53.35 |
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]
|
Facility
|
IP
|
$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: MDX Hawaii PPO |
$23.28
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]
|
Facility
|
IP
|
$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: MDX Hawaii PPO |
$32.98
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 00409000710
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 00409000701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10430]
|
Facility
|
IP
|
$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: MDX Hawaii PPO |
$23.28
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10430]
|
Facility
|
IP
|
$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: MDX Hawaii PPO |
$23.28
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10430]
|
Facility
|
IP
|
$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: MDX Hawaii PPO |
$13.58
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [169436]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 25021067376
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [169436]
|
Facility
|
IP
|
$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: MDX Hawaii PPO |
$24.25
|
|
|
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL [166770]
|
Facility
|
IP
|
$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: MDX Hawaii PPO |
$34.92
|
|
|
LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL GEL [166770]
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
NDC 70092161144
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.36 |
| Max. Negotiated Rate |
$34.92 |
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$34.20
|
| Rate for Payer: Health Management Network Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18.36
|
| Rate for Payer: MDX Hawaii PPO |
$34.92
|
| Rate for Payer: University Health Alliance Commercial |
$26.24
|
|
|
LIDOCAINE 4 % TOPICAL CREAM [23461]
|
Facility
|
IP
|
$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: MDX Hawaii PPO |
$14.55
|
|
