|
levothyroxine 100 mcg tablet [HHSC]
|
Facility
|
OP
|
$4.02
|
|
|
Service Code
|
NDC 60687049701
|
| Hospital Charge Code |
2500469
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.01 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: AlohaCare Medicaid |
$2.01
|
| Rate for Payer: AlohaCare Medicare |
$2.01
|
| Rate for Payer: Cash Price |
$2.61
|
| Rate for Payer: Devoted Health Medicare |
$2.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.82
|
| Rate for Payer: Health Management Network Commercial |
$3.42
|
| Rate for Payer: Humana Medicare |
$2.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.01
|
| Rate for Payer: MDX Hawaii PPO |
$3.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.01
|
| Rate for Payer: University Health Alliance Commercial |
$2.93
|
|
|
levothyroxine 100 mcg tablet [HHSC]
|
Facility
|
IP
|
$4.02
|
|
|
Service Code
|
NDC 60687049701
|
| Hospital Charge Code |
2500469
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.42 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Cash Price |
$2.61
|
| Rate for Payer: Health Management Network Commercial |
$3.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.62
|
| Rate for Payer: MDX Hawaii PPO |
$3.90
|
|
|
levothyroxine 100 mcg tablet [HHSC]
|
Facility
|
IP
|
$3.46
|
|
|
Service Code
|
NDC 51079044220
|
| Hospital Charge Code |
2500469
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Health Management Network Commercial |
$2.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.11
|
| Rate for Payer: MDX Hawaii PPO |
$3.36
|
|
|
levothyroxine 50 mcg tablet [HHSC]
|
Facility
|
OP
|
$3.14
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
2500472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: AlohaCare Medicaid |
$1.57
|
| Rate for Payer: AlohaCare Medicare |
$1.57
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Devoted Health Medicare |
$1.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.98
|
| Rate for Payer: Health Management Network Commercial |
$2.67
|
| Rate for Payer: Humana Medicare |
$1.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.83
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.57
|
| Rate for Payer: MDX Hawaii PPO |
$3.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.57
|
| Rate for Payer: University Health Alliance Commercial |
$2.29
|
|
|
levothyroxine 50 mcg tablet [HHSC]
|
Facility
|
OP
|
$3.05
|
|
|
Service Code
|
NDC 51079044020
|
| Hospital Charge Code |
2500472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: AlohaCare Medicaid |
$1.52
|
| Rate for Payer: AlohaCare Medicare |
$1.52
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Devoted Health Medicare |
$1.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.90
|
| Rate for Payer: Health Management Network Commercial |
$2.59
|
| Rate for Payer: Humana Medicare |
$1.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.52
|
| Rate for Payer: MDX Hawaii PPO |
$2.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.52
|
| Rate for Payer: University Health Alliance Commercial |
$2.22
|
|
|
levothyroxine 50 mcg tablet [HHSC]
|
Facility
|
IP
|
$3.05
|
|
|
Service Code
|
NDC 51079044020
|
| Hospital Charge Code |
2500472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.59 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Health Management Network Commercial |
$2.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.75
|
| Rate for Payer: MDX Hawaii PPO |
$2.96
|
|
|
levothyroxine 50 mcg tablet [HHSC]
|
Facility
|
IP
|
$3.14
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
2500472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.67 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Health Management Network Commercial |
$2.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.83
|
| Rate for Payer: MDX Hawaii PPO |
$3.05
|
|
|
lidocaine 100mg/5ml syringe [HHSC]
|
Facility
|
IP
|
$26.69
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
2500479
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.69 |
| Max. Negotiated Rate |
$25.89 |
| Rate for Payer: Cash Price |
$17.35
|
| Rate for Payer: Cash Price |
$13.36
|
| Rate for Payer: Cash Price |
$12.80
|
| Rate for Payer: Health Management Network Commercial |
$22.69
|
| Rate for Payer: Health Management Network Commercial |
$16.74
|
| Rate for Payer: Health Management Network Commercial |
$17.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.02
|
| Rate for Payer: MDX Hawaii PPO |
$19.10
|
| Rate for Payer: MDX Hawaii PPO |
$19.93
|
| Rate for Payer: MDX Hawaii PPO |
$25.89
|
|
|
lidocaine 100mg/5ml syringe [HHSC]
|
Facility
|
OP
|
$20.55
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
2500479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.28 |
| Max. Negotiated Rate |
$19.93 |
| Rate for Payer: AlohaCare Medicaid |
$10.28
|
| Rate for Payer: AlohaCare Medicaid |
$13.35
|
| Rate for Payer: AlohaCare Medicaid |
$9.85
|
| Rate for Payer: AlohaCare Medicare |
$13.35
|
| Rate for Payer: AlohaCare Medicare |
$10.28
|
| Rate for Payer: AlohaCare Medicare |
$9.85
|
| Rate for Payer: Cash Price |
$17.35
|
| Rate for Payer: Cash Price |
$12.80
|
| Rate for Payer: Cash Price |
$13.36
|
| Rate for Payer: Devoted Health Medicare |
$14.68
|
| Rate for Payer: Devoted Health Medicare |
$11.30
|
| Rate for Payer: Devoted Health Medicare |
$10.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.71
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.36
|
| Rate for Payer: Health Management Network Commercial |
$17.47
|
| Rate for Payer: Health Management Network Commercial |
$16.74
|
| Rate for Payer: Health Management Network Commercial |
$22.69
|
| Rate for Payer: Humana Medicare |
$9.85
|
| Rate for Payer: Humana Medicare |
$13.35
|
| Rate for Payer: Humana Medicare |
$10.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.35
|
| Rate for Payer: MDX Hawaii PPO |
$19.10
|
| Rate for Payer: MDX Hawaii PPO |
$25.89
|
| Rate for Payer: MDX Hawaii PPO |
$19.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.85
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.85
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.85
|
| Rate for Payer: University Health Alliance Commercial |
$19.45
|
| Rate for Payer: University Health Alliance Commercial |
$14.35
|
| Rate for Payer: University Health Alliance Commercial |
$14.98
|
|
|
lidocaine 1% 20ml vial [HHSC]
|
Facility
|
IP
|
$21.01
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
2500475
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.86 |
| Max. Negotiated Rate |
$20.38 |
| Rate for Payer: Cash Price |
$13.66
|
| Rate for Payer: Cash Price |
$6.16
|
| Rate for Payer: Cash Price |
$6.14
|
| Rate for Payer: Cash Price |
$12.79
|
| Rate for Payer: Health Management Network Commercial |
$8.03
|
| Rate for Payer: Health Management Network Commercial |
$16.73
|
| Rate for Payer: Health Management Network Commercial |
$17.86
|
| Rate for Payer: Health Management Network Commercial |
$8.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.52
|
| Rate for Payer: MDX Hawaii PPO |
$9.19
|
| Rate for Payer: MDX Hawaii PPO |
$20.38
|
| Rate for Payer: MDX Hawaii PPO |
$19.09
|
| Rate for Payer: MDX Hawaii PPO |
$9.17
|
|
|
lidocaine 1% 20ml vial [HHSC]
|
Facility
|
OP
|
$21.01
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
2500475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.51 |
| Max. Negotiated Rate |
$20.38 |
| Rate for Payer: MDX Hawaii PPO |
$9.17
|
| Rate for Payer: AlohaCare Medicaid |
$10.51
|
| Rate for Payer: AlohaCare Medicaid |
$4.74
|
| Rate for Payer: AlohaCare Medicaid |
$9.84
|
| Rate for Payer: AlohaCare Medicaid |
$4.72
|
| Rate for Payer: AlohaCare Medicare |
$10.51
|
| Rate for Payer: AlohaCare Medicare |
$4.72
|
| Rate for Payer: AlohaCare Medicare |
$4.74
|
| Rate for Payer: AlohaCare Medicare |
$9.84
|
| Rate for Payer: Cash Price |
$13.66
|
| Rate for Payer: Cash Price |
$6.14
|
| Rate for Payer: Cash Price |
$12.79
|
| Rate for Payer: Cash Price |
$6.16
|
| Rate for Payer: Devoted Health Medicare |
$5.21
|
| Rate for Payer: Devoted Health Medicare |
$5.20
|
| Rate for Payer: Devoted Health Medicare |
$10.82
|
| Rate for Payer: Devoted Health Medicare |
$11.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$16.73
|
| Rate for Payer: Health Management Network Commercial |
$17.86
|
| Rate for Payer: Health Management Network Commercial |
$8.05
|
| Rate for Payer: Health Management Network Commercial |
$8.03
|
| Rate for Payer: Humana Medicare |
$4.74
|
| Rate for Payer: Humana Medicare |
$4.72
|
| Rate for Payer: Humana Medicare |
$9.84
|
| Rate for Payer: Humana Medicare |
$10.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.83
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.84
|
| Rate for Payer: MDX Hawaii PPO |
$19.09
|
| Rate for Payer: MDX Hawaii PPO |
$20.38
|
| Rate for Payer: MDX Hawaii PPO |
$9.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.74
|
| Rate for Payer: University Health Alliance Commercial |
$14.34
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
| Rate for Payer: University Health Alliance Commercial |
$6.89
|
| Rate for Payer: University Health Alliance Commercial |
$6.90
|
|
|
lidocaine 1%-EPI 1:100,000 20 mL [HHSC]
|
Facility
|
IP
|
$13.25
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
2500297
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.26 |
| Max. Negotiated Rate |
$12.85 |
| Rate for Payer: Cash Price |
$8.61
|
| Rate for Payer: Cash Price |
$16.26
|
| Rate for Payer: Cash Price |
$10.30
|
| Rate for Payer: Health Management Network Commercial |
$21.27
|
| Rate for Payer: Health Management Network Commercial |
$11.26
|
| Rate for Payer: Health Management Network Commercial |
$13.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.52
|
| Rate for Payer: MDX Hawaii PPO |
$24.27
|
| Rate for Payer: MDX Hawaii PPO |
$12.85
|
| Rate for Payer: MDX Hawaii PPO |
$15.37
|
|
|
lidocaine 1%-EPI 1:100,000 20 mL [HHSC]
|
Facility
|
OP
|
$13.25
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
2500297
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.62 |
| Max. Negotiated Rate |
$12.85 |
| Rate for Payer: AlohaCare Medicaid |
$6.62
|
| Rate for Payer: AlohaCare Medicaid |
$7.92
|
| Rate for Payer: AlohaCare Medicaid |
$12.51
|
| Rate for Payer: AlohaCare Medicare |
$7.92
|
| Rate for Payer: AlohaCare Medicare |
$6.62
|
| Rate for Payer: AlohaCare Medicare |
$12.51
|
| Rate for Payer: Cash Price |
$10.30
|
| Rate for Payer: Cash Price |
$8.61
|
| Rate for Payer: Cash Price |
$16.26
|
| Rate for Payer: Devoted Health Medicare |
$7.29
|
| Rate for Payer: Devoted Health Medicare |
$13.76
|
| Rate for Payer: Devoted Health Medicare |
$8.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.06
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.77
|
| Rate for Payer: Health Management Network Commercial |
$13.47
|
| Rate for Payer: Health Management Network Commercial |
$11.26
|
| Rate for Payer: Health Management Network Commercial |
$21.27
|
| Rate for Payer: Humana Medicare |
$12.51
|
| Rate for Payer: Humana Medicare |
$6.62
|
| Rate for Payer: Humana Medicare |
$7.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.51
|
| Rate for Payer: MDX Hawaii PPO |
$12.85
|
| Rate for Payer: MDX Hawaii PPO |
$24.27
|
| Rate for Payer: MDX Hawaii PPO |
$15.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.92
|
| Rate for Payer: University Health Alliance Commercial |
$18.24
|
| Rate for Payer: University Health Alliance Commercial |
$9.66
|
| Rate for Payer: University Health Alliance Commercial |
$11.55
|
|
|
lidocaine 2% 20 mL vial [HHSC]
|
Facility
|
OP
|
$23.84
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
2500477
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.92 |
| Max. Negotiated Rate |
$23.12 |
| Rate for Payer: AlohaCare Medicaid |
$11.92
|
| Rate for Payer: AlohaCare Medicaid |
$12.81
|
| Rate for Payer: AlohaCare Medicaid |
$6.99
|
| Rate for Payer: AlohaCare Medicare |
$12.81
|
| Rate for Payer: AlohaCare Medicare |
$11.92
|
| Rate for Payer: AlohaCare Medicare |
$6.99
|
| Rate for Payer: Cash Price |
$16.65
|
| Rate for Payer: Cash Price |
$9.08
|
| Rate for Payer: Cash Price |
$15.50
|
| Rate for Payer: Devoted Health Medicare |
$14.09
|
| Rate for Payer: Devoted Health Medicare |
$13.11
|
| Rate for Payer: Devoted Health Medicare |
$7.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.99
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.34
|
| Rate for Payer: Health Management Network Commercial |
$20.26
|
| Rate for Payer: Health Management Network Commercial |
$11.87
|
| Rate for Payer: Health Management Network Commercial |
$21.78
|
| Rate for Payer: Humana Medicare |
$6.99
|
| Rate for Payer: Humana Medicare |
$12.81
|
| Rate for Payer: Humana Medicare |
$11.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.81
|
| Rate for Payer: MDX Hawaii PPO |
$13.55
|
| Rate for Payer: MDX Hawaii PPO |
$24.85
|
| Rate for Payer: MDX Hawaii PPO |
$23.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.99
|
| Rate for Payer: University Health Alliance Commercial |
$18.67
|
| Rate for Payer: University Health Alliance Commercial |
$10.18
|
| Rate for Payer: University Health Alliance Commercial |
$17.38
|
|
|
lidocaine 2% 20 mL vial [HHSC]
|
Facility
|
IP
|
$25.62
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
2500477
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.78 |
| Max. Negotiated Rate |
$24.85 |
| Rate for Payer: Cash Price |
$16.65
|
| Rate for Payer: Cash Price |
$15.50
|
| Rate for Payer: Cash Price |
$9.08
|
| Rate for Payer: Health Management Network Commercial |
$21.78
|
| Rate for Payer: Health Management Network Commercial |
$11.87
|
| Rate for Payer: Health Management Network Commercial |
$20.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.06
|
| Rate for Payer: MDX Hawaii PPO |
$13.55
|
| Rate for Payer: MDX Hawaii PPO |
$23.12
|
| Rate for Payer: MDX Hawaii PPO |
$24.85
|
|
|
lidocaine 2%-EPI 1:100,000 20 mL [HHSC]
|
Facility
|
IP
|
$25.35
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
2500298
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.55 |
| Max. Negotiated Rate |
$24.59 |
| Rate for Payer: Cash Price |
$16.48
|
| Rate for Payer: Cash Price |
$14.48
|
| Rate for Payer: Cash Price |
$12.97
|
| Rate for Payer: Health Management Network Commercial |
$21.55
|
| Rate for Payer: Health Management Network Commercial |
$16.96
|
| Rate for Payer: Health Management Network Commercial |
$18.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.82
|
| Rate for Payer: MDX Hawaii PPO |
$19.35
|
| Rate for Payer: MDX Hawaii PPO |
$21.60
|
| Rate for Payer: MDX Hawaii PPO |
$24.59
|
|
|
lidocaine 2%-EPI 1:100,000 20 mL [HHSC]
|
Facility
|
OP
|
$22.27
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
2500298
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.13 |
| Max. Negotiated Rate |
$21.60 |
| Rate for Payer: AlohaCare Medicaid |
$11.13
|
| Rate for Payer: AlohaCare Medicaid |
$12.68
|
| Rate for Payer: AlohaCare Medicaid |
$9.97
|
| Rate for Payer: AlohaCare Medicare |
$12.68
|
| Rate for Payer: AlohaCare Medicare |
$11.13
|
| Rate for Payer: AlohaCare Medicare |
$9.97
|
| Rate for Payer: Cash Price |
$16.48
|
| Rate for Payer: Cash Price |
$12.97
|
| Rate for Payer: Cash Price |
$14.48
|
| Rate for Payer: Devoted Health Medicare |
$13.94
|
| Rate for Payer: Devoted Health Medicare |
$12.25
|
| Rate for Payer: Devoted Health Medicare |
$10.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.08
|
| Rate for Payer: Health Management Network Commercial |
$18.93
|
| Rate for Payer: Health Management Network Commercial |
$16.96
|
| Rate for Payer: Health Management Network Commercial |
$21.55
|
| Rate for Payer: Humana Medicare |
$9.97
|
| Rate for Payer: Humana Medicare |
$12.68
|
| Rate for Payer: Humana Medicare |
$11.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.68
|
| Rate for Payer: MDX Hawaii PPO |
$19.35
|
| Rate for Payer: MDX Hawaii PPO |
$24.59
|
| Rate for Payer: MDX Hawaii PPO |
$21.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.97
|
| Rate for Payer: University Health Alliance Commercial |
$18.48
|
| Rate for Payer: University Health Alliance Commercial |
$14.54
|
| Rate for Payer: University Health Alliance Commercial |
$16.23
|
|
|
lidocaine 2% (PF) jelly 6mL syringe [HHSC]
|
Facility
|
OP
|
$44.45
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
2500897
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.23 |
| Max. Negotiated Rate |
$43.12 |
| Rate for Payer: AlohaCare Medicaid |
$22.23
|
| Rate for Payer: AlohaCare Medicare |
$22.23
|
| Rate for Payer: Cash Price |
$28.89
|
| Rate for Payer: Devoted Health Medicare |
$24.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.23
|
| Rate for Payer: Health Management Network Commercial |
$37.78
|
| Rate for Payer: Humana Medicare |
$22.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.23
|
| Rate for Payer: MDX Hawaii PPO |
$43.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.23
|
| Rate for Payer: University Health Alliance Commercial |
$32.40
|
|
|
lidocaine 2% (PF) jelly 6mL syringe [HHSC]
|
Facility
|
IP
|
$44.45
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
2500897
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.78 |
| Max. Negotiated Rate |
$43.12 |
| Rate for Payer: Cash Price |
$28.89
|
| Rate for Payer: Health Management Network Commercial |
$37.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.01
|
| Rate for Payer: MDX Hawaii PPO |
$43.12
|
|
|
lidocaine 5% patch [HHSC]
|
Facility
|
OP
|
$151.11
|
|
|
Service Code
|
NDC 61959000130
|
| Hospital Charge Code |
2500485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.56 |
| Max. Negotiated Rate |
$146.58 |
| Rate for Payer: AlohaCare Medicaid |
$75.56
|
| Rate for Payer: AlohaCare Medicare |
$75.56
|
| Rate for Payer: Cash Price |
$98.22
|
| Rate for Payer: Devoted Health Medicare |
$83.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$75.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$143.55
|
| Rate for Payer: Health Management Network Commercial |
$128.44
|
| Rate for Payer: Humana Medicare |
$75.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$136.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$77.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$75.56
|
| Rate for Payer: MDX Hawaii PPO |
$146.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$75.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$75.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$90.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$75.56
|
| Rate for Payer: University Health Alliance Commercial |
$110.14
|
|
|
lidocaine 5% patch [HHSC]
|
Facility
|
OP
|
$139.13
|
|
|
Service Code
|
NDC 63481068706
|
| Hospital Charge Code |
2500485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.56 |
| Max. Negotiated Rate |
$134.96 |
| Rate for Payer: AlohaCare Medicaid |
$69.56
|
| Rate for Payer: AlohaCare Medicare |
$69.56
|
| Rate for Payer: Cash Price |
$90.43
|
| Rate for Payer: Devoted Health Medicare |
$76.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$69.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$132.17
|
| Rate for Payer: Health Management Network Commercial |
$118.26
|
| Rate for Payer: Humana Medicare |
$69.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$125.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$69.56
|
| Rate for Payer: MDX Hawaii PPO |
$134.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$69.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$69.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$83.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$69.56
|
| Rate for Payer: University Health Alliance Commercial |
$101.41
|
|
|
lidocaine 5% patch [HHSC]
|
Facility
|
OP
|
$55.26
|
|
|
Service Code
|
NDC 00591352530
|
| Hospital Charge Code |
2500485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.63 |
| Max. Negotiated Rate |
$53.60 |
| Rate for Payer: AlohaCare Medicaid |
$27.63
|
| Rate for Payer: AlohaCare Medicare |
$27.63
|
| Rate for Payer: Cash Price |
$35.92
|
| Rate for Payer: Devoted Health Medicare |
$30.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$52.50
|
| Rate for Payer: Health Management Network Commercial |
$46.97
|
| Rate for Payer: Humana Medicare |
$27.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.63
|
| Rate for Payer: MDX Hawaii PPO |
$53.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.63
|
| Rate for Payer: University Health Alliance Commercial |
$40.28
|
|
|
lidocaine 5% patch [HHSC]
|
Facility
|
IP
|
$55.26
|
|
|
Service Code
|
NDC 00591352530
|
| Hospital Charge Code |
2500485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.97 |
| Max. Negotiated Rate |
$53.60 |
| Rate for Payer: Cash Price |
$35.92
|
| Rate for Payer: Health Management Network Commercial |
$46.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.73
|
| Rate for Payer: MDX Hawaii PPO |
$53.60
|
|
|
lidocaine 5% patch [HHSC]
|
Facility
|
IP
|
$19.98
|
|
|
Service Code
|
NDC 00603188016
|
| Hospital Charge Code |
2500485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.98 |
| Max. Negotiated Rate |
$19.38 |
| Rate for Payer: Cash Price |
$12.99
|
| Rate for Payer: Health Management Network Commercial |
$16.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.98
|
| Rate for Payer: MDX Hawaii PPO |
$19.38
|
|
|
lidocaine 5% patch [HHSC]
|
Facility
|
IP
|
$139.13
|
|
|
Service Code
|
NDC 63481068706
|
| Hospital Charge Code |
2500485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$118.26 |
| Max. Negotiated Rate |
$134.96 |
| Rate for Payer: Cash Price |
$90.43
|
| Rate for Payer: Health Management Network Commercial |
$118.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$125.22
|
| Rate for Payer: MDX Hawaii PPO |
$134.96
|
|
