|
LFITV40 FH 22.2MM 6260-9-122
|
Facility
|
OP
|
$1,990.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$995.00 |
| Max. Negotiated Rate |
$1,930.30 |
| Rate for Payer: AlohaCare Medicaid |
$995.00
|
| Rate for Payer: AlohaCare Medicare |
$1,512.40
|
| Rate for Payer: Cash Price |
$1,194.00
|
| Rate for Payer: Devoted Health Medicare |
$1,671.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,512.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,393.00
|
| Rate for Payer: Health Management Network Commercial |
$1,691.50
|
| Rate for Payer: Humana Medicare |
$1,512.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,791.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,014.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,512.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,930.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,512.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,512.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,512.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,114.40
|
|
|
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: Kaiser Permanente Commercial |
$150.30
|
| Rate for Payer: MDX Hawaii PPO |
$161.99
|
|
|
LG KNEE CRYO CUFF ONLY 11B01
|
Facility
|
OP
|
$167.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$83.50 |
| Max. Negotiated Rate |
$161.99 |
| Rate for Payer: AlohaCare Medicaid |
$83.50
|
| Rate for Payer: AlohaCare Medicare |
$126.92
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Devoted Health Medicare |
$140.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$126.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$158.65
|
| Rate for Payer: Health Management Network Commercial |
$141.95
|
| Rate for Payer: Humana Medicare |
$126.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$150.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$126.92
|
| Rate for Payer: MDX Hawaii PPO |
$161.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$126.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$126.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$126.92
|
| Rate for Payer: University Health Alliance Commercial |
$121.73
|
|
|
L HOOK ELECTRODE E3773-36C
|
Facility
|
OP
|
$174.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$87.00 |
| Max. Negotiated Rate |
$168.78 |
| Rate for Payer: AlohaCare Medicaid |
$87.00
|
| Rate for Payer: AlohaCare Medicare |
$132.24
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Devoted Health Medicare |
$146.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$132.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$165.30
|
| Rate for Payer: Health Management Network Commercial |
$147.90
|
| Rate for Payer: Humana Medicare |
$132.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$156.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$132.24
|
| Rate for Payer: MDX Hawaii PPO |
$168.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$132.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$132.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$132.24
|
| Rate for Payer: University Health Alliance Commercial |
$126.83
|
|
|
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: Kaiser Permanente Commercial |
$156.60
|
| Rate for Payer: MDX Hawaii PPO |
$168.78
|
|
|
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: Kaiser Permanente Commercial |
$49.50
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
|
|
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: Kaiser Permanente Commercial |
$30.60
|
| Rate for Payer: MDX Hawaii PPO |
$32.98
|
|
|
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: Kaiser Permanente Commercial |
$21.60
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
|
|
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: Kaiser Permanente Commercial |
$49.50
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
|
|
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: Kaiser Permanente Commercial |
$9.90
|
| 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: Kaiser Permanente Commercial |
$9.90
|
| 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: Kaiser Permanente Commercial |
$21.60
|
| 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: Kaiser Permanente Commercial |
$21.60
|
| 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: Kaiser Permanente Commercial |
$12.60
|
| 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 |
$12.50 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: AlohaCare Medicaid |
$12.50
|
| Rate for Payer: AlohaCare Medicare |
$19.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Devoted Health Medicare |
$21.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Humana Medicare |
$19.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.00
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.00
|
| 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: Kaiser Permanente Commercial |
$22.50
|
| 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: Kaiser Permanente Commercial |
$32.40
|
| 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 |
$18.00 |
| Max. Negotiated Rate |
$34.92 |
| Rate for Payer: AlohaCare Medicaid |
$18.00
|
| Rate for Payer: AlohaCare Medicare |
$27.36
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Devoted Health Medicare |
$30.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$34.20
|
| Rate for Payer: Health Management Network Commercial |
$30.60
|
| Rate for Payer: Humana Medicare |
$27.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.36
|
| Rate for Payer: MDX Hawaii PPO |
$34.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.36
|
| Rate for Payer: University Health Alliance Commercial |
$26.24
|
|
|
LIDOCAINE 4 % TOPICAL CREAM [23461]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 24357070105
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$11.40
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$12.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$11.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.40
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.40
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
LIDOCAINE 4 % TOPICAL CREAM [23461]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 24357070106
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$11.40
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$12.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$11.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.40
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.40
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
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: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
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: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [41831]
|
Facility
|
OP
|
$950.00
|
|
|
Service Code
|
NDC 64380078932
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$475.00 |
| Max. Negotiated Rate |
$921.50 |
| Rate for Payer: AlohaCare Medicaid |
$475.00
|
| Rate for Payer: AlohaCare Medicare |
$722.00
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Devoted Health Medicare |
$798.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$722.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$902.50
|
| Rate for Payer: Health Management Network Commercial |
$807.50
|
| Rate for Payer: Humana Medicare |
$722.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$855.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$484.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$722.00
|
| Rate for Payer: MDX Hawaii PPO |
$921.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$722.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$722.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$722.00
|
| 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 |
$452.50 |
| Max. Negotiated Rate |
$877.85 |
| Rate for Payer: AlohaCare Medicaid |
$452.50
|
| Rate for Payer: AlohaCare Medicare |
$687.80
|
| Rate for Payer: Cash Price |
$543.00
|
| Rate for Payer: Devoted Health Medicare |
$760.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$687.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$859.75
|
| Rate for Payer: Health Management Network Commercial |
$769.25
|
| Rate for Payer: Humana Medicare |
$687.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$814.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$461.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$687.80
|
| Rate for Payer: MDX Hawaii PPO |
$877.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$687.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$687.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$687.80
|
| Rate for Payer: University Health Alliance Commercial |
$659.65
|
|
|
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: Kaiser Permanente Commercial |
$855.00
|
| Rate for Payer: MDX Hawaii PPO |
$921.50
|
|
