|
LEVOTHYROXINE 88 MCG PO TABLET
|
Facility
|
OP
|
$3.36
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$3.33 |
| Rate for Payer: AlohaCare Medicaid |
$1.68
|
| Rate for Payer: AlohaCare Medicaid |
$1.94
|
| Rate for Payer: AlohaCare Medicare |
$3.02
|
| Rate for Payer: AlohaCare Medicare |
$3.48
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Devoted Health Medicare |
$3.33
|
| Rate for Payer: Devoted Health Medicare |
$3.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.19
|
| Rate for Payer: Health Management Network Commercial |
$2.86
|
| Rate for Payer: Health Management Network Commercial |
$3.29
|
| Rate for Payer: Humana Medicare |
$3.48
|
| Rate for Payer: Humana Medicare |
$3.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.02
|
| Rate for Payer: MDX Hawaii PPO |
$3.75
|
| Rate for Payer: MDX Hawaii PPO |
$3.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.48
|
| Rate for Payer: University Health Alliance Commercial |
$2.82
|
| Rate for Payer: University Health Alliance Commercial |
$2.45
|
|
|
LIDOCAINE 4 % TOP CR
|
Facility
|
OP
|
$57.48
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.74 |
| Max. Negotiated Rate |
$56.91 |
| Rate for Payer: AlohaCare Medicaid |
$28.74
|
| Rate for Payer: AlohaCare Medicare |
$51.73
|
| Rate for Payer: Cash Price |
$37.36
|
| Rate for Payer: Devoted Health Medicare |
$56.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$51.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$54.61
|
| Rate for Payer: Health Management Network Commercial |
$48.86
|
| Rate for Payer: Humana Medicare |
$51.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$51.73
|
| Rate for Payer: MDX Hawaii PPO |
$55.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$51.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$51.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$51.73
|
| Rate for Payer: University Health Alliance Commercial |
$41.90
|
|
|
LIDOCAINE 4 % TOP CR
|
Facility
|
IP
|
$57.48
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.86 |
| Max. Negotiated Rate |
$55.76 |
| Rate for Payer: Cash Price |
$37.36
|
| Rate for Payer: Health Management Network Commercial |
$48.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.73
|
| Rate for Payer: MDX Hawaii PPO |
$55.76
|
|
|
LIDOCAINE 5 %(700 MG/PATCH) TOP PTMD
|
Facility
|
OP
|
$54.87
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.43 |
| Max. Negotiated Rate |
$54.32 |
| Rate for Payer: AlohaCare Medicaid |
$27.43
|
| Rate for Payer: AlohaCare Medicaid |
$7.87
|
| Rate for Payer: AlohaCare Medicare |
$14.17
|
| Rate for Payer: AlohaCare Medicare |
$49.38
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Cash Price |
$35.67
|
| Rate for Payer: Devoted Health Medicare |
$54.32
|
| Rate for Payer: Devoted Health Medicare |
$15.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$52.13
|
| Rate for Payer: Health Management Network Commercial |
$46.64
|
| Rate for Payer: Health Management Network Commercial |
$13.38
|
| Rate for Payer: Humana Medicare |
$49.38
|
| Rate for Payer: Humana Medicare |
$14.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.38
|
| Rate for Payer: MDX Hawaii PPO |
$15.27
|
| Rate for Payer: MDX Hawaii PPO |
$53.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.17
|
| Rate for Payer: University Health Alliance Commercial |
$39.99
|
| Rate for Payer: University Health Alliance Commercial |
$11.47
|
|
|
LIDOCAINE 5 %(700 MG/PATCH) TOP PTMD
|
Facility
|
IP
|
$15.74
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.38 |
| Max. Negotiated Rate |
$15.27 |
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Cash Price |
$35.67
|
| Rate for Payer: Health Management Network Commercial |
$13.38
|
| Rate for Payer: Health Management Network Commercial |
$46.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.38
|
| Rate for Payer: MDX Hawaii PPO |
$53.22
|
| Rate for Payer: MDX Hawaii PPO |
$15.27
|
|
|
LIDOCAINE 5 % TOP OINT
|
Facility
|
OP
|
$897.38
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$448.69 |
| Max. Negotiated Rate |
$888.41 |
| Rate for Payer: AlohaCare Medicaid |
$448.69
|
| Rate for Payer: AlohaCare Medicare |
$807.64
|
| Rate for Payer: Cash Price |
$583.30
|
| Rate for Payer: Devoted Health Medicare |
$888.41
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$807.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$852.51
|
| Rate for Payer: Health Management Network Commercial |
$762.77
|
| Rate for Payer: Humana Medicare |
$807.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$807.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$457.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$807.64
|
| Rate for Payer: MDX Hawaii PPO |
$870.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$807.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$807.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$807.64
|
| Rate for Payer: University Health Alliance Commercial |
$654.10
|
|
|
LIDOCAINE 5 % TOP OINT
|
Facility
|
IP
|
$897.38
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$762.77 |
| Max. Negotiated Rate |
$870.46 |
| Rate for Payer: Cash Price |
$583.30
|
| Rate for Payer: Health Management Network Commercial |
$762.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$807.64
|
| Rate for Payer: MDX Hawaii PPO |
$870.46
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJ SOLN
|
Facility
|
IP
|
$115.29
|
|
|
Service Code
|
NDC 63323048902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.00 |
| Max. Negotiated Rate |
$111.83 |
| Rate for Payer: Cash Price |
$74.94
|
| Rate for Payer: Health Management Network Commercial |
$98.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.76
|
| Rate for Payer: MDX Hawaii PPO |
$111.83
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJ SOLN
|
Facility
|
OP
|
$115.29
|
|
|
Service Code
|
NDC 63323048902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.65 |
| Max. Negotiated Rate |
$114.14 |
| Rate for Payer: AlohaCare Medicaid |
$57.65
|
| Rate for Payer: AlohaCare Medicare |
$103.76
|
| Rate for Payer: Cash Price |
$74.94
|
| Rate for Payer: Devoted Health Medicare |
$114.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$103.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$109.53
|
| Rate for Payer: Health Management Network Commercial |
$98.00
|
| Rate for Payer: Humana Medicare |
$103.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$103.76
|
| Rate for Payer: MDX Hawaii PPO |
$111.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$103.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$103.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$69.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$103.76
|
| Rate for Payer: University Health Alliance Commercial |
$84.03
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJ SOLN
|
Facility
|
IP
|
$17.56
|
|
|
Service Code
|
NDC 00409427601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.93 |
| Max. Negotiated Rate |
$17.03 |
| Rate for Payer: Cash Price |
$11.41
|
| Rate for Payer: Health Management Network Commercial |
$14.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.80
|
| Rate for Payer: MDX Hawaii PPO |
$17.03
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJ SOLN
|
Facility
|
IP
|
$17.56
|
|
|
Service Code
|
NDC 00409427616
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.93 |
| Max. Negotiated Rate |
$17.03 |
| Rate for Payer: Cash Price |
$11.41
|
| Rate for Payer: Health Management Network Commercial |
$14.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.80
|
| Rate for Payer: MDX Hawaii PPO |
$17.03
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJ SOLN
|
Facility
|
OP
|
$17.56
|
|
|
Service Code
|
NDC 00409427601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.78 |
| Max. Negotiated Rate |
$17.38 |
| Rate for Payer: AlohaCare Medicaid |
$8.78
|
| Rate for Payer: AlohaCare Medicare |
$15.80
|
| Rate for Payer: Cash Price |
$11.41
|
| Rate for Payer: Devoted Health Medicare |
$17.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.68
|
| Rate for Payer: Health Management Network Commercial |
$14.93
|
| Rate for Payer: Humana Medicare |
$15.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.80
|
| Rate for Payer: MDX Hawaii PPO |
$17.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.80
|
| Rate for Payer: University Health Alliance Commercial |
$12.80
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJ SOLN
|
Facility
|
OP
|
$17.56
|
|
|
Service Code
|
NDC 00409427616
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.78 |
| Max. Negotiated Rate |
$17.38 |
| Rate for Payer: AlohaCare Medicaid |
$8.78
|
| Rate for Payer: AlohaCare Medicare |
$15.80
|
| Rate for Payer: Cash Price |
$11.41
|
| Rate for Payer: Devoted Health Medicare |
$17.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.68
|
| Rate for Payer: Health Management Network Commercial |
$14.93
|
| Rate for Payer: Humana Medicare |
$15.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.80
|
| Rate for Payer: MDX Hawaii PPO |
$17.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.80
|
| Rate for Payer: University Health Alliance Commercial |
$12.80
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJ SOLN
|
Facility
|
OP
|
$21.20
|
|
|
Service Code
|
NDC 63323048602
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.60 |
| Max. Negotiated Rate |
$20.99 |
| Rate for Payer: AlohaCare Medicaid |
$10.60
|
| Rate for Payer: AlohaCare Medicare |
$19.08
|
| Rate for Payer: Cash Price |
$13.78
|
| Rate for Payer: Devoted Health Medicare |
$20.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.14
|
| Rate for Payer: Health Management Network Commercial |
$18.02
|
| Rate for Payer: Humana Medicare |
$19.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.08
|
| Rate for Payer: MDX Hawaii PPO |
$20.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.08
|
| Rate for Payer: University Health Alliance Commercial |
$15.45
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJ SOLN
|
Facility
|
IP
|
$21.20
|
|
|
Service Code
|
NDC 63323048602
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.02 |
| Max. Negotiated Rate |
$20.56 |
| Rate for Payer: Cash Price |
$13.78
|
| Rate for Payer: Health Management Network Commercial |
$18.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.08
|
| Rate for Payer: MDX Hawaii PPO |
$20.56
|
|
|
LIDOCAINE HCL 2 % MM JELP
|
Facility
|
IP
|
$32.86
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.93 |
| Max. Negotiated Rate |
$31.87 |
| Rate for Payer: Cash Price |
$21.36
|
| Rate for Payer: Health Management Network Commercial |
$27.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.57
|
| Rate for Payer: MDX Hawaii PPO |
$31.87
|
|
|
LIDOCAINE HCL 2 % MM JELP
|
Facility
|
OP
|
$32.86
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.43 |
| Max. Negotiated Rate |
$32.53 |
| Rate for Payer: AlohaCare Medicaid |
$16.43
|
| Rate for Payer: AlohaCare Medicare |
$29.57
|
| Rate for Payer: Cash Price |
$21.36
|
| Rate for Payer: Devoted Health Medicare |
$32.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.22
|
| Rate for Payer: Health Management Network Commercial |
$27.93
|
| Rate for Payer: Humana Medicare |
$29.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.57
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.57
|
| Rate for Payer: MDX Hawaii PPO |
$31.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.57
|
| Rate for Payer: University Health Alliance Commercial |
$23.95
|
|
|
LIDOCAINE HCL 2 % MM SOLN
|
Facility
|
IP
|
$91.03
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.38 |
| Max. Negotiated Rate |
$88.30 |
| Rate for Payer: Cash Price |
$59.17
|
| Rate for Payer: Cash Price |
$30.43
|
| Rate for Payer: Health Management Network Commercial |
$77.38
|
| Rate for Payer: Health Management Network Commercial |
$39.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.14
|
| Rate for Payer: MDX Hawaii PPO |
$45.42
|
| Rate for Payer: MDX Hawaii PPO |
$88.30
|
|
|
LIDOCAINE HCL 2 % MM SOLN
|
Facility
|
OP
|
$46.82
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.41 |
| Max. Negotiated Rate |
$46.35 |
| Rate for Payer: AlohaCare Medicaid |
$23.41
|
| Rate for Payer: AlohaCare Medicaid |
$45.52
|
| Rate for Payer: AlohaCare Medicare |
$42.14
|
| Rate for Payer: AlohaCare Medicare |
$81.93
|
| Rate for Payer: Cash Price |
$59.17
|
| Rate for Payer: Cash Price |
$30.43
|
| Rate for Payer: Devoted Health Medicare |
$46.35
|
| Rate for Payer: Devoted Health Medicare |
$90.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$81.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$42.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$86.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.48
|
| Rate for Payer: Health Management Network Commercial |
$39.80
|
| Rate for Payer: Health Management Network Commercial |
$77.38
|
| Rate for Payer: Humana Medicare |
$81.93
|
| Rate for Payer: Humana Medicare |
$42.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$46.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$81.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$42.14
|
| Rate for Payer: MDX Hawaii PPO |
$88.30
|
| Rate for Payer: MDX Hawaii PPO |
$45.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$42.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$81.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$42.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$81.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$42.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$81.93
|
| Rate for Payer: University Health Alliance Commercial |
$66.35
|
| Rate for Payer: University Health Alliance Commercial |
$34.13
|
|
|
LIDOCAINE HCL 4 % MM SOLN
|
Facility
|
IP
|
$18.22
|
|
|
Service Code
|
NDC RPKWH000693
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.49 |
| Max. Negotiated Rate |
$17.67 |
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Health Management Network Commercial |
$15.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.40
|
| Rate for Payer: MDX Hawaii PPO |
$17.67
|
|
|
LIDOCAINE HCL 4 % MM SOLN
|
Facility
|
OP
|
$18.22
|
|
|
Service Code
|
NDC RPKWH000693
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.11 |
| Max. Negotiated Rate |
$18.04 |
| Rate for Payer: AlohaCare Medicaid |
$9.11
|
| Rate for Payer: AlohaCare Medicare |
$16.40
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Devoted Health Medicare |
$18.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.31
|
| Rate for Payer: Health Management Network Commercial |
$15.49
|
| Rate for Payer: Humana Medicare |
$16.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.40
|
| Rate for Payer: MDX Hawaii PPO |
$17.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.40
|
| Rate for Payer: University Health Alliance Commercial |
$13.28
|
|
|
LIDOCAINE HCL (PF) 1 % (10 MG/ML) INJ SOLN (5 ML)
|
Facility
|
OP
|
$21.70
|
|
|
Service Code
|
NDC 63323049209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.85 |
| Max. Negotiated Rate |
$21.48 |
| Rate for Payer: AlohaCare Medicaid |
$10.85
|
| Rate for Payer: AlohaCare Medicare |
$19.53
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Devoted Health Medicare |
$21.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.61
|
| Rate for Payer: Health Management Network Commercial |
$18.45
|
| Rate for Payer: Humana Medicare |
$19.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.53
|
| Rate for Payer: MDX Hawaii PPO |
$21.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.53
|
| Rate for Payer: University Health Alliance Commercial |
$15.82
|
|
|
LIDOCAINE HCL (PF) 1 % (10 MG/ML) INJ SOLN (5 ML)
|
Facility
|
IP
|
$21.70
|
|
|
Service Code
|
NDC 63323049209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.45 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Health Management Network Commercial |
$18.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.53
|
| Rate for Payer: MDX Hawaii PPO |
$21.05
|
|
|
LIDOCAINE HCL (PF) 1 % (10 MG/ML) INJ SOLN (5 ML)
|
Facility
|
IP
|
$21.70
|
|
|
Service Code
|
NDC 63323049257
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.45 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Health Management Network Commercial |
$18.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.53
|
| Rate for Payer: MDX Hawaii PPO |
$21.05
|
|
|
LIDOCAINE HCL (PF) 1 % (10 MG/ML) INJ SOLN (5 ML)
|
Facility
|
OP
|
$21.70
|
|
|
Service Code
|
NDC 63323049257
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.85 |
| Max. Negotiated Rate |
$21.48 |
| Rate for Payer: AlohaCare Medicaid |
$10.85
|
| Rate for Payer: AlohaCare Medicare |
$19.53
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Devoted Health Medicare |
$21.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.61
|
| Rate for Payer: Health Management Network Commercial |
$18.45
|
| Rate for Payer: Humana Medicare |
$19.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.53
|
| Rate for Payer: MDX Hawaii PPO |
$21.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.53
|
| Rate for Payer: University Health Alliance Commercial |
$15.82
|
|
