Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]

Facility

IP

$71.00

Service Code	NDC 00168025815
Hospital Revenue Code	250
Min. Negotiated Rate	$60.35
Max. Negotiated Rate	$68.87
Rate for Payer: Cash Price	$42.60
Rate for Payer: Health Management Network Commercial	$60.35
Rate for Payer: Kaiser Permanente Commercial	$63.90
Rate for Payer: MDX Hawaii PPO	$68.87

CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]

Facility

IP

$197.00

Service Code	NDC 68462029817
Hospital Revenue Code	250
Min. Negotiated Rate	$167.45
Max. Negotiated Rate	$191.09
Rate for Payer: Cash Price	$118.20
Rate for Payer: Health Management Network Commercial	$167.45
Rate for Payer: Kaiser Permanente Commercial	$177.30
Rate for Payer: MDX Hawaii PPO	$191.09

CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]

Facility

IP

$293.00

Service Code	NDC 00472037945
Hospital Revenue Code	250
Min. Negotiated Rate	$249.05
Max. Negotiated Rate	$284.21
Rate for Payer: Cash Price	$175.80
Rate for Payer: Health Management Network Commercial	$249.05
Rate for Payer: Kaiser Permanente Commercial	$263.70
Rate for Payer: MDX Hawaii PPO	$284.21

CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]

Facility

IP

$136.00

Service Code	NDC 00472037915
Hospital Revenue Code	250
Min. Negotiated Rate	$115.60
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$81.60
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Kaiser Permanente Commercial	$122.40
Rate for Payer: MDX Hawaii PPO	$131.92

CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]

Facility

IP

$153.00

Service Code	NDC 00168025846
Hospital Revenue Code	250
Min. Negotiated Rate	$130.05
Max. Negotiated Rate	$148.41
Rate for Payer: Cash Price	$91.80
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Kaiser Permanente Commercial	$137.70
Rate for Payer: MDX Hawaii PPO	$148.41

CLOZAPINE 100 MG TABLET [9647]

Facility

IP

$13.00

Service Code	NDC 60687041501
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: MDX Hawaii PPO	$12.61

CLOZAPINE 100 MG TABLET [9647]

Facility

OP

$13.00

Service Code	NDC 60687041511
Hospital Revenue Code	637
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$12.61
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$9.88
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$10.92
Rate for Payer: Hawaii Medical Service Association Medicare	$9.88
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Humana Medicare	$9.88
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: Kaiser Permanente Medicare	$9.88
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: Ohana Health Plan Medicaid	$9.88
Rate for Payer: Ohana Health Plan Medicare	$9.88
Rate for Payer: UnitedHealthcare Medicare	$9.88
Rate for Payer: University Health Alliance Commercial	$9.48

CLOZAPINE 100 MG TABLET [9647]

Facility

OP

$13.00

Service Code	NDC 60687041501
Hospital Revenue Code	637
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$12.61
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$9.88
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$10.92
Rate for Payer: Hawaii Medical Service Association Medicare	$9.88
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Humana Medicare	$9.88
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: Kaiser Permanente Medicare	$9.88
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: Ohana Health Plan Medicaid	$9.88
Rate for Payer: Ohana Health Plan Medicare	$9.88
Rate for Payer: UnitedHealthcare Medicare	$9.88
Rate for Payer: University Health Alliance Commercial	$9.48

CLOZAPINE 100 MG TABLET [9647]

Facility

IP

$13.00

Service Code	NDC 60687041511
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: MDX Hawaii PPO	$12.61

CLOZAPINE 25 MG TABLET [9648]

Facility

IP

$5.00

Service Code	NDC 60687040411
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

CLOZAPINE 25 MG TABLET [9648]

Facility

OP

$5.00

Service Code	NDC 60687040401
Hospital Revenue Code	637
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$3.80
Rate for Payer: Cash Price	$3.00
Rate for Payer: Devoted Health Medicare	$4.20
Rate for Payer: Hawaii Medical Service Association Medicare	$3.80
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$3.80
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$3.80
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$3.80
Rate for Payer: Ohana Health Plan Medicare	$3.80
Rate for Payer: UnitedHealthcare Medicare	$3.80
Rate for Payer: University Health Alliance Commercial	$3.64

CLOZAPINE 25 MG TABLET [9648]

Facility

IP

$5.00

Service Code	NDC 60687040401
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

CLOZAPINE 25 MG TABLET [9648]

Facility

OP

$5.00

Service Code	NDC 60687040411
Hospital Revenue Code	637
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$3.80
Rate for Payer: Cash Price	$3.00
Rate for Payer: Devoted Health Medicare	$4.20
Rate for Payer: Hawaii Medical Service Association Medicare	$3.80
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$3.80
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$3.80
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$3.80
Rate for Payer: Ohana Health Plan Medicare	$3.80
Rate for Payer: UnitedHealthcare Medicare	$3.80
Rate for Payer: University Health Alliance Commercial	$3.64

CLSTERHLE SHELL48MM 702-04-48D

Facility

IP

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,816.64
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Kaiser Permanente Commercial	$2,919.60
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

CLSTERHLE SHELL48MM 702-04-48D

Facility

OP

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,622.00
Max. Negotiated Rate	$3,146.68
Rate for Payer: AlohaCare Medicaid	$1,622.00
Rate for Payer: AlohaCare Medicare	$2,465.44
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Devoted Health Medicare	$2,724.96
Rate for Payer: Hawaii Medical Service Association Medicare	$2,465.44
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Humana Medicare	$2,465.44
Rate for Payer: Kaiser Permanente Commercial	$2,919.60
Rate for Payer: Kaiser Permanente Medicaid	$1,654.44
Rate for Payer: Kaiser Permanente Medicare	$2,465.44
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: Ohana Health Plan Medicaid	$2,465.44
Rate for Payer: Ohana Health Plan Medicare	$2,465.44
Rate for Payer: UnitedHealthcare Medicare	$2,465.44
Rate for Payer: University Health Alliance Commercial	$1,816.64

CLSTERHLE SHELL50MM 702-04-50D

Facility

OP

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,605.50
Max. Negotiated Rate	$3,114.67
Rate for Payer: AlohaCare Medicaid	$1,605.50
Rate for Payer: AlohaCare Medicare	$2,440.36
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Devoted Health Medicare	$2,697.24
Rate for Payer: Hawaii Medical Service Association Medicare	$2,440.36
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Humana Medicare	$2,440.36
Rate for Payer: Kaiser Permanente Commercial	$2,889.90
Rate for Payer: Kaiser Permanente Medicaid	$1,637.61
Rate for Payer: Kaiser Permanente Medicare	$2,440.36
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: Ohana Health Plan Medicaid	$2,440.36
Rate for Payer: Ohana Health Plan Medicare	$2,440.36
Rate for Payer: UnitedHealthcare Medicare	$2,440.36
Rate for Payer: University Health Alliance Commercial	$1,798.16

CLSTERHLE SHELL50MM 702-04-50D

Facility

IP

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,798.16
Max. Negotiated Rate	$3,114.67
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Kaiser Permanente Commercial	$2,889.90
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: University Health Alliance Commercial	$1,798.16

CLSTR SHEL 50HH 00-8757-050-01

Facility

OP

$4,684.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,342.00
Max. Negotiated Rate	$4,543.48
Rate for Payer: AlohaCare Medicaid	$2,342.00
Rate for Payer: AlohaCare Medicare	$3,559.84
Rate for Payer: Cash Price	$2,810.40
Rate for Payer: Devoted Health Medicare	$3,934.56
Rate for Payer: Hawaii Medical Service Association Medicare	$3,559.84
Rate for Payer: Hawaii Western Management Group Commercial	$3,278.80
Rate for Payer: Health Management Network Commercial	$3,981.40
Rate for Payer: Humana Medicare	$3,559.84
Rate for Payer: Kaiser Permanente Commercial	$4,215.60
Rate for Payer: Kaiser Permanente Medicaid	$2,388.84
Rate for Payer: Kaiser Permanente Medicare	$3,559.84
Rate for Payer: MDX Hawaii PPO	$4,543.48
Rate for Payer: Ohana Health Plan Medicaid	$3,559.84
Rate for Payer: Ohana Health Plan Medicare	$3,559.84
Rate for Payer: UnitedHealthcare Medicare	$3,559.84
Rate for Payer: University Health Alliance Commercial	$2,623.04

CLSTR SHEL 50HH 00-8757-050-01

Facility

IP

$4,684.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,623.04
Max. Negotiated Rate	$4,543.48
Rate for Payer: Cash Price	$2,810.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,278.80
Rate for Payer: Health Management Network Commercial	$3,981.40
Rate for Payer: Kaiser Permanente Commercial	$4,215.60
Rate for Payer: MDX Hawaii PPO	$4,543.48
Rate for Payer: University Health Alliance Commercial	$2,623.04

CLSTR SHEL 54JJ 00-8757-054-01

Facility

OP

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$3,344.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Devoted Health Medicare	$3,696.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,344.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$3,344.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$3,344.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$3,344.00
Rate for Payer: Ohana Health Plan Medicare	$3,344.00
Rate for Payer: UnitedHealthcare Medicare	$3,344.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CLSTR SHEL 54JJ 00-8757-054-01

Facility

IP

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CLSTR SHEL 56KK 00-8757-056-01

Facility

OP

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$3,344.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Devoted Health Medicare	$3,696.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,344.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$3,344.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$3,344.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$3,344.00
Rate for Payer: Ohana Health Plan Medicare	$3,344.00
Rate for Payer: UnitedHealthcare Medicare	$3,344.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CLSTR SHEL 56KK 00-8757-056-01

Facility

IP

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CLSTR SHEL 60MM 00-8757-060-01

Facility

OP

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$3,344.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Devoted Health Medicare	$3,696.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,344.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$3,344.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$3,344.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$3,344.00
Rate for Payer: Ohana Health Plan Medicare	$3,344.00
Rate for Payer: UnitedHealthcare Medicare	$3,344.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CLSTR SHEL 60MM 00-8757-060-01

Facility

IP

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

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