|
LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 00121495040
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
|
LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 00121495040
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: AlohaCare Medicaid |
$13.50
|
| Rate for Payer: AlohaCare Medicare |
$20.52
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Devoted Health Medicare |
$22.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Humana Medicare |
$20.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.52
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.52
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
|
|
LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 00121495015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
|
LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 00121495015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: AlohaCare Medicaid |
$13.50
|
| Rate for Payer: AlohaCare Medicare |
$20.52
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Devoted Health Medicare |
$22.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Humana Medicare |
$20.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.52
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.52
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
NDC 70954051810
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.50 |
| Max. Negotiated Rate |
$220.19 |
| Rate for Payer: AlohaCare Medicaid |
$113.50
|
| Rate for Payer: AlohaCare Medicare |
$172.52
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Devoted Health Medicare |
$190.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$172.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$215.65
|
| Rate for Payer: Health Management Network Commercial |
$192.95
|
| Rate for Payer: Humana Medicare |
$172.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$204.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$115.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$172.52
|
| Rate for Payer: MDX Hawaii PPO |
$220.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$172.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$172.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$172.52
|
| Rate for Payer: University Health Alliance Commercial |
$165.46
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
NDC 00054350547
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$142.80 |
| Max. Negotiated Rate |
$162.96 |
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Health Management Network Commercial |
$142.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.20
|
| Rate for Payer: MDX Hawaii PPO |
$162.96
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
NDC 00054350547
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$162.96 |
| Rate for Payer: AlohaCare Medicaid |
$84.00
|
| Rate for Payer: AlohaCare Medicare |
$127.68
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Devoted Health Medicare |
$141.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$127.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$159.60
|
| Rate for Payer: Health Management Network Commercial |
$142.80
|
| Rate for Payer: Humana Medicare |
$127.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$127.68
|
| Rate for Payer: MDX Hawaii PPO |
$162.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$127.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$127.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$127.68
|
| Rate for Payer: University Health Alliance Commercial |
$122.46
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
NDC 70954051810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$192.95 |
| Max. Negotiated Rate |
$220.19 |
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Health Management Network Commercial |
$192.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$204.30
|
| Rate for Payer: MDX Hawaii PPO |
$220.19
|
|
|
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION [43717]
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
NDC 76329630005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$92.65 |
| Max. Negotiated Rate |
$105.73 |
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Health Management Network Commercial |
$92.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$98.10
|
| Rate for Payer: MDX Hawaii PPO |
$105.73
|
|
|
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION [43717]
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
NDC 76329630005
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.50 |
| Max. Negotiated Rate |
$105.73 |
| Rate for Payer: AlohaCare Medicaid |
$54.50
|
| Rate for Payer: AlohaCare Medicare |
$82.84
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Devoted Health Medicare |
$91.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$82.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$103.55
|
| Rate for Payer: Health Management Network Commercial |
$92.65
|
| Rate for Payer: Humana Medicare |
$82.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$98.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$82.84
|
| Rate for Payer: MDX Hawaii PPO |
$105.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$82.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$82.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$82.84
|
| Rate for Payer: University Health Alliance Commercial |
$79.45
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [166252]
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 00409132305
|
|
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: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [166252]
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
NDC 00409490334
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.20 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [166252]
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
NDC 76329339001
|
|
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: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [166252]
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 00409132315
|
|
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: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 55150016205
|
|
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 (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: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 73293000101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 73293000102
|
|
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 (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 55150015974
|
|
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: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [104207]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 55150016102
|
|
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 (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: Kaiser Permanente Commercial |
$27.90
|
| 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: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
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: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
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: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
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: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
