|
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
|
$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
|
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 2 % MUCOSAL JELLY IN APPLICATOR [169436]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 25021067376
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.75 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: AlohaCare Medicaid |
$12.50
|
| Rate for Payer: AlohaCare Medicare |
$7.75
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Devoted Health Medicare |
$8.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Humana Medicare |
$7.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.75
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.75
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
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 |
$11.16 |
| Max. Negotiated Rate |
$34.92 |
| Rate for Payer: AlohaCare Medicaid |
$18.00
|
| Rate for Payer: AlohaCare Medicare |
$11.16
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Devoted Health Medicare |
$12.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$34.20
|
| Rate for Payer: Health Management Network Commercial |
$30.60
|
| Rate for Payer: Humana Medicare |
$11.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.16
|
| Rate for Payer: MDX Hawaii PPO |
$34.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.16
|
| Rate for Payer: University Health Alliance Commercial |
$26.24
|
|
|
LIDOCAINE 4 % TOPICAL CREAM [23461]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 24357070106
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$4.65
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$4.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
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 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
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 24357070105
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$4.65
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$4.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
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: Kaiser Permanente Commercial |
$814.50
|
| Rate for Payer: MDX Hawaii PPO |
$877.85
|
|
|
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
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [41831]
|
Facility
|
OP
|
$905.00
|
|
|
Service Code
|
NDC 33342040535
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$280.55 |
| Max. Negotiated Rate |
$877.85 |
| Rate for Payer: AlohaCare Medicaid |
$452.50
|
| Rate for Payer: AlohaCare Medicare |
$280.55
|
| Rate for Payer: Cash Price |
$543.00
|
| Rate for Payer: Devoted Health Medicare |
$307.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$280.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$859.75
|
| Rate for Payer: Health Management Network Commercial |
$769.25
|
| Rate for Payer: Humana Medicare |
$280.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$814.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$461.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$280.55
|
| Rate for Payer: MDX Hawaii PPO |
$877.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$280.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$280.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$280.55
|
| Rate for Payer: University Health Alliance Commercial |
$659.65
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [41831]
|
Facility
|
OP
|
$950.00
|
|
|
Service Code
|
NDC 64380078932
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$294.50 |
| Max. Negotiated Rate |
$921.50 |
| Rate for Payer: AlohaCare Medicaid |
$475.00
|
| Rate for Payer: AlohaCare Medicare |
$294.50
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Devoted Health Medicare |
$323.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$294.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$902.50
|
| Rate for Payer: Health Management Network Commercial |
$807.50
|
| Rate for Payer: Humana Medicare |
$294.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$855.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$484.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$294.50
|
| Rate for Payer: MDX Hawaii PPO |
$921.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$294.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$294.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$294.50
|
| Rate for Payer: University Health Alliance Commercial |
$692.46
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [41831]
|
Facility
|
OP
|
$950.00
|
|
|
Service Code
|
NDC 68462041820
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$294.50 |
| Max. Negotiated Rate |
$921.50 |
| Rate for Payer: AlohaCare Medicaid |
$475.00
|
| Rate for Payer: AlohaCare Medicare |
$294.50
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Devoted Health Medicare |
$323.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$294.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$902.50
|
| Rate for Payer: Health Management Network Commercial |
$807.50
|
| Rate for Payer: Humana Medicare |
$294.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$855.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$484.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$294.50
|
| Rate for Payer: MDX Hawaii PPO |
$921.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$294.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$294.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$294.50
|
| Rate for Payer: University Health Alliance Commercial |
$692.46
|
|
|
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: Kaiser Permanente Commercial |
$855.00
|
| Rate for Payer: MDX Hawaii PPO |
$921.50
|
|
|
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: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 82347050505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicare |
$3.72
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Devoted Health Medicare |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Humana Medicare |
$3.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.72
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.72
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 82347050504
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicare |
$3.72
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Devoted Health Medicare |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Humana Medicare |
$3.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.72
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.72
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
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: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
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: Kaiser Permanente Commercial |
$75.60
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
|
|
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: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
|
