|
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 |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| 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 |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
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 |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| 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 |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
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 |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
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 |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
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 |
$0.25 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| 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 |
$0.25 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| 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 |
$0.25 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Senior |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
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 |
$0.25 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Senior |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| 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 |
$0.10 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.42
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Senior |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
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 |
$0.10 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| 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 |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Senior |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
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 |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| 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 |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
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 |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Senior |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
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 |
$12.22 |
| Max. Negotiated Rate |
$75.67 |
| Rate for Payer: Adventist Health Commercial |
$13.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$36.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$46.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$57.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$37.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$50.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.67
|
| Rate for Payer: Blue Shield of California Commercial |
$27.00
|
| Rate for Payer: Blue Shield of California EPN |
$27.00
|
| Rate for Payer: Cash Price |
$37.15
|
| Rate for Payer: Cash Price |
$37.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$57.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$57.41
|
| Rate for Payer: Dignity Health Senior |
$57.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.27
|
| Rate for Payer: Heritage Provider Network Senior |
$31.27
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$52.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$32.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$47.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$47.28
|
| Rate for Payer: Multiplan Commercial |
$50.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$27.02
|
| Rate for Payer: TriValley Medical Group Senior |
$27.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$57.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$57.41
|
| Rate for Payer: Vantage Medical Group Senior |
$57.41
|
|
|
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 |
$12.22 |
| Max. Negotiated Rate |
$50.66 |
| Rate for Payer: Adventist Health Commercial |
$13.51
|
| Rate for Payer: Cash Price |
$37.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.27
|
| Rate for Payer: Heritage Provider Network Senior |
$31.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.89
|
| Rate for Payer: Multiplan Commercial |
$50.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.36
|
|
|
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 |
$11.88 |
| Max. Negotiated Rate |
$49.22 |
| Rate for Payer: Adventist Health Commercial |
$13.12
|
| Rate for Payer: Cash Price |
$36.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.38
|
| Rate for Payer: Heritage Provider Network Senior |
$30.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.41
|
| Rate for Payer: Multiplan Commercial |
$49.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$21.73
|
|
|
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 |
$11.88 |
| Max. Negotiated Rate |
$75.67 |
| Rate for Payer: Adventist Health Commercial |
$13.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$35.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$45.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$55.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$36.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$49.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.67
|
| Rate for Payer: Blue Shield of California Commercial |
$27.00
|
| Rate for Payer: Blue Shield of California EPN |
$27.00
|
| Rate for Payer: Cash Price |
$36.09
|
| Rate for Payer: Cash Price |
$36.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$55.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$55.78
|
| Rate for Payer: Dignity Health Senior |
$55.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.38
|
| Rate for Payer: Heritage Provider Network Senior |
$30.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$52.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$31.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$45.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$45.93
|
| Rate for Payer: Multiplan Commercial |
$49.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$26.25
|
| Rate for Payer: TriValley Medical Group Senior |
$26.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$21.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$55.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$55.78
|
| Rate for Payer: Vantage Medical Group Senior |
$55.78
|
|
|
DIPHTH,PERTUS(AC)TETANUS VAC (PF) 2 LF-(5-3-5MCG)-5LF/0.5ML IM WRAP [408119727]
|
Facility
|
OP
|
$112.68
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.40 |
| Max. Negotiated Rate |
$121.81 |
| Rate for Payer: Adventist Health Commercial |
$22.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$60.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$121.81
|
| Rate for Payer: Blue Shield of California Commercial |
$46.78
|
| Rate for Payer: Blue Shield of California EPN |
$46.78
|
| Rate for Payer: Cash Price |
$61.97
|
| Rate for Payer: Cash Price |
$61.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.78
|
| Rate for Payer: Dignity Health Senior |
$95.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.17
|
| Rate for Payer: Heritage Provider Network Senior |
$52.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$39.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$53.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$78.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78.88
|
| Rate for Payer: Multiplan Commercial |
$84.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$45.07
|
| Rate for Payer: TriValley Medical Group Senior |
$45.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.78
|
| Rate for Payer: Vantage Medical Group Senior |
$95.78
|
|
|
DIPHTH,PERTUS(AC)TETANUS VAC (PF) 2 LF-(5-3-5MCG)-5LF/0.5ML IM WRAP [408119727]
|
Facility
|
IP
|
$112.68
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.40 |
| Max. Negotiated Rate |
$84.51 |
| Rate for Payer: Adventist Health Commercial |
$22.54
|
| Rate for Payer: Cash Price |
$61.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.17
|
| Rate for Payer: Heritage Provider Network Senior |
$52.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.17
|
| Rate for Payer: Multiplan Commercial |
$84.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.31
|
|
