|
LIDOCAINE 4 % TOPICAL CREAM [23461]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 24357070105
|
|
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
|
|
|
LIDOCAINE 4 % TOPICAL CREAM [23461]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 24357070106
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
LIDOCAINE 4 % TOPICAL CREAM [23461]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 24357070105
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [41831]
|
Facility
|
IP
|
$950.00
|
|
|
Service Code
|
NDC 64380078932
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$807.50 |
| Max. Negotiated Rate |
$921.50 |
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Health Management Network Commercial |
$807.50
|
| Rate for Payer: MDX Hawaii PPO |
$921.50
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [41831]
|
Facility
|
IP
|
$905.00
|
|
|
Service Code
|
NDC 33342040535
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$769.25 |
| Max. Negotiated Rate |
$877.85 |
| Rate for Payer: Cash Price |
$543.00
|
| Rate for Payer: Health Management Network Commercial |
$769.25
|
| Rate for Payer: MDX Hawaii PPO |
$877.85
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [41831]
|
Facility
|
OP
|
$950.00
|
|
|
Service Code
|
NDC 68462041820
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$484.50 |
| Max. Negotiated Rate |
$921.50 |
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$902.50
|
| Rate for Payer: Health Management Network Commercial |
$807.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$598.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$484.50
|
| Rate for Payer: MDX Hawaii PPO |
$921.50
|
| Rate for Payer: University Health Alliance Commercial |
$692.46
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [41831]
|
Facility
|
OP
|
$950.00
|
|
|
Service Code
|
NDC 64380078932
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$484.50 |
| Max. Negotiated Rate |
$921.50 |
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$902.50
|
| Rate for Payer: Health Management Network Commercial |
$807.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$598.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$484.50
|
| Rate for Payer: MDX Hawaii PPO |
$921.50
|
| Rate for Payer: University Health Alliance Commercial |
$692.46
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [41831]
|
Facility
|
OP
|
$905.00
|
|
|
Service Code
|
NDC 33342040535
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$461.55 |
| Max. Negotiated Rate |
$877.85 |
| Rate for Payer: Cash Price |
$543.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$859.75
|
| Rate for Payer: Health Management Network Commercial |
$769.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$570.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$461.55
|
| Rate for Payer: MDX Hawaii PPO |
$877.85
|
| Rate for Payer: University Health Alliance Commercial |
$659.65
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [41831]
|
Facility
|
IP
|
$950.00
|
|
|
Service Code
|
NDC 68462041820
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$807.50 |
| Max. Negotiated Rate |
$921.50 |
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Health Management Network Commercial |
$807.50
|
| Rate for Payer: MDX Hawaii PPO |
$921.50
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
NDC 63481068706
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.80 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.00
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.80
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
| Rate for Payer: University Health Alliance Commercial |
$58.31
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 82347050504
|
|
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: MDX Hawaii PPO |
$11.64
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 82347050505
|
|
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: MDX Hawaii PPO |
$11.64
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
|
IP
|
$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: MDX Hawaii PPO |
$28.13
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
NDC 61959000130
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$71.40 |
| Max. Negotiated Rate |
$81.48 |
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Health Management Network Commercial |
$71.40
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
NDC 00591267930
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.79 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.55
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.79
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
| Rate for Payer: University Health Alliance Commercial |
$21.14
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
NDC 00591352530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.79 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.55
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.79
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
| Rate for Payer: University Health Alliance Commercial |
$21.14
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
NDC 63481068706
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.00 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
NDC 61959000130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.84 |
| Max. Negotiated Rate |
$81.48 |
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$79.80
|
| Rate for Payer: Health Management Network Commercial |
$71.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.92
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.84
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
| Rate for Payer: University Health Alliance Commercial |
$61.23
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
|
IP
|
$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: MDX Hawaii PPO |
$28.13
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 82347050504
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 82347050505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [10431]
|
Facility
|
IP
|
$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: MDX Hawaii PPO |
$96.03
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [10431]
|
Facility
|
IP
|
$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: MDX Hawaii PPO |
$96.03
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]
|
Facility
|
IP
|
$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: MDX Hawaii PPO |
$13.58
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]
|
Facility
|
IP
|
$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: MDX Hawaii PPO |
$13.58
|
|
