|
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: Kaiser Permanente Commercial |
$26.10
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
|
|
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
|
$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
|
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: Kaiser Permanente Commercial |
$26.10
|
| 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 |
$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 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-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: Kaiser Permanente Commercial |
$89.10
|
| 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: Kaiser Permanente Commercial |
$89.10
|
| Rate for Payer: MDX Hawaii PPO |
$96.03
|
|
|
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: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 63323020110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
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: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 63323020103
|
|
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 HCL 20 MG/ML (2 %) INJECTION SOLUTION [4454]
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
HCPCS J2003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.27 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: AlohaCare Medicaid |
$8.50
|
| Rate for Payer: AlohaCare Medicare |
$5.27
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Devoted Health Medicare |
$5.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Humana Medicare |
$5.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.27
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.27
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION [4454]
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
HCPCS J2003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.45 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
|
|
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
|
IP
|
$47.00
|
|
|
Service Code
|
NDC 72888012526
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.95 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
|
|
LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 00121495015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.37 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: AlohaCare Medicaid |
$13.50
|
| Rate for Payer: AlohaCare Medicare |
$8.37
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Devoted Health Medicare |
$9.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Humana Medicare |
$8.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.37
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.37
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
|
|
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
|
$47.00
|
|
|
Service Code
|
NDC 72888012526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.57 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: AlohaCare Medicaid |
$23.50
|
| Rate for Payer: AlohaCare Medicare |
$14.57
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Devoted Health Medicare |
$15.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.65
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Humana Medicare |
$14.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.57
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.57
|
| Rate for Payer: University Health Alliance Commercial |
$34.26
|
|
|
LIDOCAINE HCL 2 % MUCOSAL SOLUTION [27898]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 00121495040
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.37 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: AlohaCare Medicaid |
$13.50
|
| Rate for Payer: AlohaCare Medicare |
$8.37
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Devoted Health Medicare |
$9.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Humana Medicare |
$8.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.37
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.37
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
|
|
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 % (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
|
$227.00
|
|
|
Service Code
|
NDC 70954051810
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.37 |
| Max. Negotiated Rate |
$220.19 |
| Rate for Payer: AlohaCare Medicaid |
$113.50
|
| Rate for Payer: AlohaCare Medicare |
$70.37
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Devoted Health Medicare |
$77.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$70.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$215.65
|
| Rate for Payer: Health Management Network Commercial |
$192.95
|
| Rate for Payer: Humana Medicare |
$70.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$204.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$115.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$70.37
|
| Rate for Payer: MDX Hawaii PPO |
$220.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$70.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$70.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$70.37
|
| Rate for Payer: University Health Alliance Commercial |
$165.46
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
NDC 00054350547
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.08 |
| Max. Negotiated Rate |
$162.96 |
| Rate for Payer: AlohaCare Medicaid |
$84.00
|
| Rate for Payer: AlohaCare Medicare |
$52.08
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Devoted Health Medicare |
$57.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$159.60
|
| Rate for Payer: Health Management Network Commercial |
$142.80
|
| Rate for Payer: Humana Medicare |
$52.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$52.08
|
| Rate for Payer: MDX Hawaii PPO |
$162.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.08
|
| Rate for Payer: University Health Alliance Commercial |
$122.46
|
|
|
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
|
|
