|
CLONAZEPAM 0.5 MG TABLET [9637]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687054401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
CLONAZEPAM 0.5 MG TABLET [9637]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687086101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
CLONAZEPAM 0.5 MG TABLET [9637]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687054401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687055501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687087201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687087211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687055501
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687087201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687087211
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [162634]
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
NDC 75907002348
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.33 |
| Max. Negotiated Rate |
$80.51 |
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$78.85
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.33
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
| Rate for Payer: University Health Alliance Commercial |
$60.50
|
|
|
CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [162634]
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
NDC 75907002311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.33 |
| Max. Negotiated Rate |
$80.51 |
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$78.85
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.33
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
| Rate for Payer: University Health Alliance Commercial |
$60.50
|
|
|
CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [162634]
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
NDC 75907002348
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.55 |
| Max. Negotiated Rate |
$80.51 |
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
|
|
CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [162634]
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
NDC 00591350804
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.33 |
| Max. Negotiated Rate |
$80.51 |
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$78.85
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.33
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
| Rate for Payer: University Health Alliance Commercial |
$60.50
|
|
|
CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [162634]
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
NDC 75907002311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.55 |
| Max. Negotiated Rate |
$80.51 |
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
|
|
CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [162634]
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
NDC 00591350804
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.55 |
| Max. Negotiated Rate |
$80.51 |
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
|
|
CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH [162635]
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
NDC 75907002448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$95.20 |
| Max. Negotiated Rate |
$108.64 |
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Health Management Network Commercial |
$95.20
|
| Rate for Payer: MDX Hawaii PPO |
$108.64
|
|
|
CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH [162635]
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
NDC 00591350904
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.12 |
| Max. Negotiated Rate |
$108.64 |
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.40
|
| Rate for Payer: Health Management Network Commercial |
$95.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$57.12
|
| Rate for Payer: MDX Hawaii PPO |
$108.64
|
| Rate for Payer: University Health Alliance Commercial |
$81.64
|
|
|
CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH [162635]
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
NDC 00591350904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$95.20 |
| Max. Negotiated Rate |
$108.64 |
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Health Management Network Commercial |
$95.20
|
| Rate for Payer: MDX Hawaii PPO |
$108.64
|
|
|
CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH [162635]
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
NDC 75907002411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$95.20 |
| Max. Negotiated Rate |
$108.64 |
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Health Management Network Commercial |
$95.20
|
| Rate for Payer: MDX Hawaii PPO |
$108.64
|
|
|
CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH [162635]
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
NDC 75907002448
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.12 |
| Max. Negotiated Rate |
$108.64 |
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.40
|
| Rate for Payer: Health Management Network Commercial |
$95.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$57.12
|
| Rate for Payer: MDX Hawaii PPO |
$108.64
|
| Rate for Payer: University Health Alliance Commercial |
$81.64
|
|
|
CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH [162635]
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
NDC 75907002411
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.12 |
| Max. Negotiated Rate |
$108.64 |
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.40
|
| Rate for Payer: Health Management Network Commercial |
$95.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$57.12
|
| Rate for Payer: MDX Hawaii PPO |
$108.64
|
| Rate for Payer: University Health Alliance Commercial |
$81.64
|
|
|
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH [162636]
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
NDC 75907002511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.75 |
| Max. Negotiated Rate |
$150.35 |
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Health Management Network Commercial |
$131.75
|
| Rate for Payer: MDX Hawaii PPO |
$150.35
|
|
|
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH [162636]
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
NDC 75907002548
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.75 |
| Max. Negotiated Rate |
$150.35 |
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Health Management Network Commercial |
$131.75
|
| Rate for Payer: MDX Hawaii PPO |
$150.35
|
|
|
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH [162636]
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
NDC 51862045504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.75 |
| Max. Negotiated Rate |
$150.35 |
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Health Management Network Commercial |
$131.75
|
| Rate for Payer: MDX Hawaii PPO |
$150.35
|
|
|
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH [162636]
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
NDC 00591351004
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$79.05 |
| Max. Negotiated Rate |
$150.35 |
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$147.25
|
| Rate for Payer: Health Management Network Commercial |
$131.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$97.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$79.05
|
| Rate for Payer: MDX Hawaii PPO |
$150.35
|
| Rate for Payer: University Health Alliance Commercial |
$112.98
|
|
