|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 63323049227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 55150016505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 63323049509
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 00409428212
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 63323049527
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 00409428202
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [104208]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 00409206605
|
|
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 (PF) 3.5 % EYE GEL [94220]
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
NDC 82584079201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.35 |
| Max. Negotiated Rate |
$68.87 |
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Health Management Network Commercial |
$60.35
|
| Rate for Payer: MDX Hawaii PPO |
$68.87
|
|
|
LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION [14868]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS J2002
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION [14868]
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS J2002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| 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 Western Management Group Commercial |
$26.60
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.80
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
|
|
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION [14869]
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
HCPCS J2001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.38 |
| Max. Negotiated Rate |
$36.86 |
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.10
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.38
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.80
|
| Rate for Payer: University Health Alliance Commercial |
$27.70
|
|
|
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION [14869]
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
HCPCS J2001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.30 |
| Max. Negotiated Rate |
$36.86 |
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00168035755
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.75 |
| Max. Negotiated Rate |
$33.95 |
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Health Management Network Commercial |
$29.75
|
| Rate for Payer: MDX Hawaii PPO |
$33.95
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00168035705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.75 |
| Max. Negotiated Rate |
$33.95 |
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Health Management Network Commercial |
$29.75
|
| Rate for Payer: MDX Hawaii PPO |
$33.95
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00168035755
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$33.95 |
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$33.25
|
| Rate for Payer: Health Management Network Commercial |
$29.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$17.85
|
| Rate for Payer: MDX Hawaii PPO |
$33.95
|
| Rate for Payer: University Health Alliance Commercial |
$25.51
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00168035705
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$33.95 |
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$33.25
|
| Rate for Payer: Health Management Network Commercial |
$29.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$17.85
|
| Rate for Payer: MDX Hawaii PPO |
$33.95
|
| Rate for Payer: University Health Alliance Commercial |
$25.51
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
NDC 62332058231
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.60 |
| Max. Negotiated Rate |
$93.12 |
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Health Management Network Commercial |
$81.60
|
| Rate for Payer: MDX Hawaii PPO |
$93.12
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
NDC 62332058231
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.96 |
| Max. Negotiated Rate |
$93.12 |
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$91.20
|
| Rate for Payer: Health Management Network Commercial |
$81.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$48.96
|
| Rate for Payer: MDX Hawaii PPO |
$93.12
|
| Rate for Payer: University Health Alliance Commercial |
$69.97
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT [30183]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 24357070107
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
|
|
LIGASURE ADVANCE SPD#LF5544
|
Facility
|
OP
|
$2,200.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,122.00 |
| Max. Negotiated Rate |
$2,134.00 |
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,090.00
|
| Rate for Payer: Health Management Network Commercial |
$1,870.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,386.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,122.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,134.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,603.58
|
|
|
LIGASURE ADVANCE SPD#LF5544
|
Facility
|
IP
|
$2,200.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,870.00 |
| Max. Negotiated Rate |
$2,134.00 |
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Health Management Network Commercial |
$1,870.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,134.00
|
|
|
LIGASURE EXACT DISSECT LF2019
|
Facility
|
OP
|
$1,521.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$775.71 |
| Max. Negotiated Rate |
$1,475.37 |
| Rate for Payer: Cash Price |
$912.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,444.95
|
| Rate for Payer: Health Management Network Commercial |
$1,292.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$958.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$775.71
|
| Rate for Payer: MDX Hawaii PPO |
$1,475.37
|
| Rate for Payer: University Health Alliance Commercial |
$1,108.66
|
|
|
LIGASURE EXACT DISSECT LF2019
|
Facility
|
IP
|
$1,521.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,292.85 |
| Max. Negotiated Rate |
$1,475.37 |
| Rate for Payer: Cash Price |
$912.60
|
| Rate for Payer: Health Management Network Commercial |
$1,292.85
|
| Rate for Payer: MDX Hawaii PPO |
$1,475.37
|
|
|
LIGASURE L-HOOK 5X44 LF5644
|
Facility
|
IP
|
$1,814.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,541.90 |
| Max. Negotiated Rate |
$1,759.58 |
| Rate for Payer: Cash Price |
$1,088.40
|
| Rate for Payer: Health Management Network Commercial |
$1,541.90
|
| Rate for Payer: MDX Hawaii PPO |
$1,759.58
|
|
|
LIGASURE L-HOOK 5X44 LF5644
|
Facility
|
OP
|
$1,814.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$925.14 |
| Max. Negotiated Rate |
$1,759.58 |
| Rate for Payer: Cash Price |
$1,088.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,723.30
|
| Rate for Payer: Health Management Network Commercial |
$1,541.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,142.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$925.14
|
| Rate for Payer: MDX Hawaii PPO |
$1,759.58
|
| Rate for Payer: University Health Alliance Commercial |
$1,322.22
|
|
