|
DIAZEPAM 5 MG TABLET [2405]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 51079-285-01
|
| Hospital Charge Code |
1730081
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.06
|
|
|
DIAZEPAM 5 MG TABLET [2405]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 51079-285-01
|
| Hospital Charge Code |
1730081
|
|
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: 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 Beech St/Commercial/PHCS |
$0.06
|
|
|
DIAZOXIDE 50 MG/ML ORAL SUSPENSION [19713]
|
Facility
|
OP
|
$16.26
|
|
|
Service Code
|
NDC 0575-6200-30
|
| Hospital Charge Code |
1719052
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.94 |
| Max. Negotiated Rate |
$12.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.76
|
| Rate for Payer: Cash Price |
$7.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$12.20
|
|
|
DIAZOXIDE 50 MG/ML ORAL SUSPENSION [19713]
|
Facility
|
IP
|
$16.26
|
|
|
Service Code
|
NDC 0575-6200-30
|
| Hospital Charge Code |
1719052
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.94 |
| Max. Negotiated Rate |
$13.01 |
| Rate for Payer: Cash Price |
$7.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$12.20
|
|
|
DICLOFENAC 0.1 % EYE DROPS [19714]
|
Facility
|
OP
|
$3.36
|
|
|
Service Code
|
NDC 61314-014-05
|
| Hospital Charge Code |
NDG19714
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.02
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.52
|
|
|
DICLOFENAC 0.1 % EYE DROPS [19714]
|
Facility
|
IP
|
$3.36
|
|
|
Service Code
|
NDC 61314-014-05
|
| Hospital Charge Code |
NDG19714
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.52
|
|
|
DICLOFENAC 0.1 % EYE DROPS [19714]
|
Facility
|
IP
|
$3.36
|
|
|
Service Code
|
NDC 24208-457-05
|
| Hospital Charge Code |
NDG19714
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.52
|
|
|
DICLOFENAC 0.1 % EYE DROPS [19714]
|
Facility
|
OP
|
$3.36
|
|
|
Service Code
|
NDC 24208-457-05
|
| Hospital Charge Code |
NDG19714
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.02
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.52
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 45802-160-00
|
| Hospital Charge Code |
1743762
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 65162-833-66
|
| Hospital Charge Code |
1743762
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 21922-009-09
|
| Hospital Charge Code |
1743762
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.18
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 0067-8152-03
|
| Hospital Charge Code |
1743762
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.12
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 21922-009-09
|
| Hospital Charge Code |
1743762
|
|
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 |
$0.11
|
| 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 Beech St/Commercial/PHCS |
$0.18
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 65162-833-66
|
| Hospital Charge Code |
1743762
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 0067-8152-03
|
| Hospital Charge Code |
1743762
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.12 |
| 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 |
$0.07
|
| 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 Beech St/Commercial/PHCS |
$0.12
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 69097-524-44
|
| Hospital Charge Code |
1743762
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 69097-524-44
|
| Hospital Charge Code |
1743762
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 45802-160-00
|
| Hospital Charge Code |
1743762
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 45802-953-01
|
| Hospital Charge Code |
1743762
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0067-8152-04
|
| Hospital Charge Code |
NDG100611A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 45802-953-01
|
| Hospital Charge Code |
1743762
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
DICLOFENAC 1 % TOPICAL GEL [100611]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0067-8152-04
|
| Hospital Charge Code |
NDG100611A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| 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 |
$0.06
|
| 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 |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
DICLOFENAC SODIUM 50 MG TABLET,DELAYED RELEASE [15340]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 0228-2550-11
|
| Hospital Charge Code |
1711358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.23
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
DICLOFENAC SODIUM 50 MG TABLET,DELAYED RELEASE [15340]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 51079-466-01
|
| Hospital Charge Code |
1711358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
DICLOFENAC SODIUM 50 MG TABLET,DELAYED RELEASE [15340]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 0228-2550-11
|
| Hospital Charge Code |
1711358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
