|
LEVOTHYROXINE 25 MCG PO TABLET
|
Facility
|
OP
|
$3.09
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.94
|
| Rate for Payer: Health Management Network Commercial |
$2.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.58
|
| Rate for Payer: MDX Hawaii PPO |
$3.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.85
|
| Rate for Payer: University Health Alliance Commercial |
$2.25
|
|
|
LEVOTHYROXINE 50 MCG PO TABLET
|
Facility
|
OP
|
$2.74
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Cash Price |
$1.78
|
| Rate for Payer: Cash Price |
$2.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.96
|
| Rate for Payer: Health Management Network Commercial |
$2.33
|
| Rate for Payer: Health Management Network Commercial |
$2.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.59
|
| Rate for Payer: MDX Hawaii PPO |
$2.66
|
| Rate for Payer: MDX Hawaii PPO |
$3.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.64
|
| Rate for Payer: University Health Alliance Commercial |
$2.00
|
| Rate for Payer: University Health Alliance Commercial |
$2.27
|
|
|
LEVOTHYROXINE 50 MCG PO TABLET
|
Facility
|
IP
|
$3.12
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$3.03 |
| Rate for Payer: Cash Price |
$2.03
|
| Rate for Payer: Cash Price |
$1.78
|
| Rate for Payer: Health Management Network Commercial |
$2.33
|
| Rate for Payer: Health Management Network Commercial |
$2.65
|
| Rate for Payer: MDX Hawaii PPO |
$3.03
|
| Rate for Payer: MDX Hawaii PPO |
$2.66
|
|
|
LEVOTHYROXINE 75 MCG PO TABLET
|
Facility
|
IP
|
$3.29
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$3.19 |
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Health Management Network Commercial |
$2.80
|
| Rate for Payer: Health Management Network Commercial |
$3.31
|
| Rate for Payer: MDX Hawaii PPO |
$3.19
|
| Rate for Payer: MDX Hawaii PPO |
$3.78
|
|
|
LEVOTHYROXINE 75 MCG PO TABLET
|
Facility
|
OP
|
$3.90
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.71
|
| Rate for Payer: Health Management Network Commercial |
$2.80
|
| Rate for Payer: Health Management Network Commercial |
$3.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.68
|
| Rate for Payer: MDX Hawaii PPO |
$3.19
|
| Rate for Payer: MDX Hawaii PPO |
$3.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.34
|
| Rate for Payer: University Health Alliance Commercial |
$2.84
|
| Rate for Payer: University Health Alliance Commercial |
$2.40
|
|
|
LEVOTHYROXINE 88 MCG PO TABLET
|
Facility
|
IP
|
$3.36
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Health Management Network Commercial |
$3.29
|
| Rate for Payer: Health Management Network Commercial |
$2.86
|
| Rate for Payer: MDX Hawaii PPO |
$3.26
|
| Rate for Payer: MDX Hawaii PPO |
$3.75
|
|
|
LEVOTHYROXINE 88 MCG PO TABLET
|
Facility
|
OP
|
$3.36
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.19
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.68
|
| Rate for Payer: Health Management Network Commercial |
$2.86
|
| Rate for Payer: Health Management Network Commercial |
$3.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.97
|
| Rate for Payer: MDX Hawaii PPO |
$3.26
|
| Rate for Payer: MDX Hawaii PPO |
$3.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.02
|
| Rate for Payer: University Health Alliance Commercial |
$2.45
|
| Rate for Payer: University Health Alliance Commercial |
$2.82
|
|
|
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: MDX Hawaii PPO |
$55.76
|
|
|
LIDOCAINE 4 % TOP CR
|
Facility
|
OP
|
$57.48
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.31 |
| Max. Negotiated Rate |
$55.76 |
| Rate for Payer: Cash Price |
$37.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$54.61
|
| Rate for Payer: Health Management Network Commercial |
$48.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.31
|
| Rate for Payer: MDX Hawaii PPO |
$55.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.49
|
| Rate for Payer: University Health Alliance Commercial |
$41.90
|
|
|
LIDOCAINE 5 %(700 MG/PATCH) TOP PTMD
|
Facility
|
IP
|
$54.87
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.64 |
| Max. Negotiated Rate |
$53.22 |
| Rate for Payer: Cash Price |
$35.67
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Health Management Network Commercial |
$13.38
|
| Rate for Payer: Health Management Network Commercial |
$46.64
|
| Rate for Payer: MDX Hawaii PPO |
$53.22
|
| Rate for Payer: MDX Hawaii PPO |
$15.27
|
|
|
LIDOCAINE 5 %(700 MG/PATCH) TOP PTMD
|
Facility
|
OP
|
$15.74
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.03 |
| Max. Negotiated Rate |
$15.27 |
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Cash Price |
$35.67
|
| 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 |
$13.38
|
| Rate for Payer: Health Management Network Commercial |
$46.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.57
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.98
|
| Rate for Payer: MDX Hawaii PPO |
$15.27
|
| Rate for Payer: MDX Hawaii PPO |
$53.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$32.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.44
|
| Rate for Payer: University Health Alliance Commercial |
$11.47
|
| Rate for Payer: University Health Alliance Commercial |
$39.99
|
|
|
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: MDX Hawaii PPO |
$870.46
|
|
|
LIDOCAINE 5 % TOP OINT
|
Facility
|
OP
|
$897.38
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$457.66 |
| Max. Negotiated Rate |
$870.46 |
| Rate for Payer: Cash Price |
$583.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$852.51
|
| Rate for Payer: Health Management Network Commercial |
$762.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$565.35
|
| Rate for Payer: Kaiser Permanente Medicaid |
$457.66
|
| Rate for Payer: MDX Hawaii PPO |
$870.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$538.43
|
| Rate for Payer: University Health Alliance Commercial |
$654.10
|
|
|
LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN
|
Facility
|
IP
|
$48.05
|
|
|
Service Code
|
NDC 00409317818
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.84 |
| Max. Negotiated Rate |
$46.61 |
| Rate for Payer: Cash Price |
$31.23
|
| Rate for Payer: Health Management Network Commercial |
$40.84
|
| Rate for Payer: MDX Hawaii PPO |
$46.61
|
|
|
LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN
|
Facility
|
IP
|
$30.92
|
|
|
Service Code
|
NDC 63323048203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.28 |
| Max. Negotiated Rate |
$29.99 |
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Health Management Network Commercial |
$26.28
|
| Rate for Payer: MDX Hawaii PPO |
$29.99
|
|
|
LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN
|
Facility
|
OP
|
$48.05
|
|
|
Service Code
|
NDC 00409317818
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.51 |
| Max. Negotiated Rate |
$46.61 |
| Rate for Payer: Cash Price |
$31.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$45.65
|
| Rate for Payer: Health Management Network Commercial |
$40.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.51
|
| Rate for Payer: MDX Hawaii PPO |
$46.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.83
|
| Rate for Payer: University Health Alliance Commercial |
$35.02
|
|
|
LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN
|
Facility
|
OP
|
$30.92
|
|
|
Service Code
|
NDC 63323048203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.77 |
| Max. Negotiated Rate |
$29.99 |
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.37
|
| Rate for Payer: Health Management Network Commercial |
$26.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.77
|
| Rate for Payer: MDX Hawaii PPO |
$29.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.55
|
| Rate for Payer: University Health Alliance Commercial |
$22.54
|
|
|
LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN
|
Facility
|
IP
|
$30.92
|
|
|
Service Code
|
NDC 63323048227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.28 |
| Max. Negotiated Rate |
$29.99 |
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Health Management Network Commercial |
$26.28
|
| Rate for Payer: MDX Hawaii PPO |
$29.99
|
|
|
LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN
|
Facility
|
OP
|
$30.92
|
|
|
Service Code
|
NDC 63323048227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.77 |
| Max. Negotiated Rate |
$29.99 |
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.37
|
| Rate for Payer: Health Management Network Commercial |
$26.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.77
|
| Rate for Payer: MDX Hawaii PPO |
$29.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.55
|
| Rate for Payer: University Health Alliance Commercial |
$22.54
|
|
|
LIDOCAINE-EPINEPHRINE 2 %-1:100,000 INJ SOLN
|
Facility
|
OP
|
$31.36
|
|
|
Service Code
|
NDC 63323048327
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.99 |
| Max. Negotiated Rate |
$30.42 |
| Rate for Payer: Cash Price |
$20.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.79
|
| Rate for Payer: Health Management Network Commercial |
$26.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.99
|
| Rate for Payer: MDX Hawaii PPO |
$30.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.82
|
| Rate for Payer: University Health Alliance Commercial |
$22.86
|
|
|
LIDOCAINE-EPINEPHRINE 2 %-1:100,000 INJ SOLN
|
Facility
|
IP
|
$31.36
|
|
|
Service Code
|
NDC 63323048303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.66 |
| Max. Negotiated Rate |
$30.42 |
| Rate for Payer: Cash Price |
$20.38
|
| Rate for Payer: Health Management Network Commercial |
$26.66
|
| Rate for Payer: MDX Hawaii PPO |
$30.42
|
|
|
LIDOCAINE-EPINEPHRINE 2 %-1:100,000 INJ SOLN
|
Facility
|
IP
|
$31.36
|
|
|
Service Code
|
NDC 63323048327
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.66 |
| Max. Negotiated Rate |
$30.42 |
| Rate for Payer: Cash Price |
$20.38
|
| Rate for Payer: Health Management Network Commercial |
$26.66
|
| Rate for Payer: MDX Hawaii PPO |
$30.42
|
|
|
LIDOCAINE-EPINEPHRINE 2 %-1:100,000 INJ SOLN
|
Facility
|
OP
|
$31.36
|
|
|
Service Code
|
NDC 63323048303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.99 |
| Max. Negotiated Rate |
$30.42 |
| Rate for Payer: Cash Price |
$20.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.79
|
| Rate for Payer: Health Management Network Commercial |
$26.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.99
|
| Rate for Payer: MDX Hawaii PPO |
$30.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.82
|
| Rate for Payer: University Health Alliance Commercial |
$22.86
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJ SOLN
|
Facility
|
OP
|
$115.29
|
|
|
Service Code
|
NDC 63323048927
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$111.83 |
| Rate for Payer: Cash Price |
$74.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$109.53
|
| Rate for Payer: Health Management Network Commercial |
$98.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.80
|
| Rate for Payer: MDX Hawaii PPO |
$111.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$69.17
|
| Rate for Payer: University Health Alliance Commercial |
$84.03
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJ SOLN
|
Facility
|
OP
|
$115.29
|
|
|
Service Code
|
NDC 63323048902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$111.83 |
| Rate for Payer: Cash Price |
$74.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$109.53
|
| Rate for Payer: Health Management Network Commercial |
$98.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.80
|
| Rate for Payer: MDX Hawaii PPO |
$111.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$69.17
|
| Rate for Payer: University Health Alliance Commercial |
$84.03
|
|
