Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

DIPHENHYDRAMINE-ZINC ACETATE 1 %-0.1 % TOPICAL CREAM [22409]

Facility

OP

$0.13

Service Code	NDC 58232-07401
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [16299]

Facility

OP

$0.16

Service Code	NDC 1254717167
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [16299]

Facility

IP

$0.09

Service Code	NDC 24385-210-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [16299]

Facility

IP

$0.16

Service Code	NDC 1254717167
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [16299]

Facility

IP

$0.09

Service Code	NDC 45802-358-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [16299]

Facility

OP

$0.08

Service Code	NDC 0904-5354-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [16299]

Facility

OP

$0.09

Service Code	NDC 24385-210-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [16299]

Facility

IP

$0.08

Service Code	NDC 0904-5354-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [16299]

Facility

OP

$0.09

Service Code	NDC 45802-358-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID [2515]

Facility

OP

$1.40

Service Code	NDC 0054-3194-46
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.84
Rate for Payer: Aetna of CA Government/Medicare	$0.84
Rate for Payer: Cash Price	$0.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.12
Rate for Payer: Health Smart Auto/Commercial	$0.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.84
Rate for Payer: LLUH Dept of Risk Management WC	$0.77
Rate for Payer: Multiplan Commercial	$1.05

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID [2515]

Facility

IP

$1.40

Service Code	NDC 9999-2515-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.12
Rate for Payer: Cash Price	$0.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.12
Rate for Payer: Health Smart Auto/Commercial	$0.84
Rate for Payer: LLUH Dept of Risk Management WC	$0.77
Rate for Payer: Multiplan Commercial	$1.05

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID [2515]

Facility

IP

$1.40

Service Code	NDC 0054-3194-46
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.12
Rate for Payer: Cash Price	$0.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.12
Rate for Payer: Health Smart Auto/Commercial	$0.84
Rate for Payer: LLUH Dept of Risk Management WC	$0.77
Rate for Payer: Multiplan Commercial	$1.05

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID [2515]

Facility

OP

$1.40

Service Code	NDC 9999-2515-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.84
Rate for Payer: Aetna of CA Government/Medicare	$0.84
Rate for Payer: Cash Price	$0.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.12
Rate for Payer: Health Smart Auto/Commercial	$0.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.84
Rate for Payer: LLUH Dept of Risk Management WC	$0.77
Rate for Payer: Multiplan Commercial	$1.05

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]

Facility

IP

$0.56

Service Code	NDC 69315-910-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.45
Rate for Payer: Cash Price	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.42

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]

Facility

OP

$0.49

Service Code	NDC 59762-1061-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]

Facility

IP

$0.20

Service Code	NDC 62559-490-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]

Facility

IP

$0.49

Service Code	NDC 59762-1061-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]

Facility

IP

$0.23

Service Code	NDC 0406-1236-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.17

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]

Facility

OP

$0.56

Service Code	NDC 69315-910-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.34
Rate for Payer: Aetna of CA Government/Medicare	$0.34
Rate for Payer: Cash Price	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.42

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]

Facility

OP

$0.23

Service Code	NDC 0406-1236-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.17

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]

Facility

OP

$0.20

Service Code	NDC 62559-490-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP [119613]

Facility

OP

$67.54

Service Code	HCPCS 90700
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$37.15
Max. Negotiated Rate	$54.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.52
Rate for Payer: Aetna of CA Government/Medicare	$40.52
Rate for Payer: Cash Price	$37.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$54.03
Rate for Payer: Health Smart Auto/Commercial	$40.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.52
Rate for Payer: LLUH Dept of Risk Management WC	$37.15
Rate for Payer: Multiplan Commercial	$50.66

DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP [119613]

Facility

IP

$67.54

Service Code	HCPCS 90700
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$37.15
Max. Negotiated Rate	$54.03
Rate for Payer: Cash Price	$37.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$54.03
Rate for Payer: Health Smart Auto/Commercial	$40.52
Rate for Payer: LLUH Dept of Risk Management WC	$37.15
Rate for Payer: Multiplan Commercial	$50.66

DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]

Facility

IP

$65.62

Service Code	HCPCS 90700
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$36.09
Max. Negotiated Rate	$52.50
Rate for Payer: Cash Price	$36.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.50
Rate for Payer: Health Smart Auto/Commercial	$39.37
Rate for Payer: LLUH Dept of Risk Management WC	$36.09
Rate for Payer: Multiplan Commercial	$49.22

DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]

Facility

OP

$65.62

Service Code	HCPCS 90700
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$36.09
Max. Negotiated Rate	$52.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.37
Rate for Payer: Aetna of CA Government/Medicare	$39.37
Rate for Payer: Cash Price	$36.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.50
Rate for Payer: Health Smart Auto/Commercial	$39.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.37
Rate for Payer: LLUH Dept of Risk Management WC	$36.09
Rate for Payer: Multiplan Commercial	$49.22

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