Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]

Facility

$0.91

Service Code	NDC 0121-0489-05
Hospital Charge Code	1716039
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.73
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna of CA HMO/PPO	$0.73
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]

Facility

$0.38

Service Code	NDC 68094-022-62
Hospital Charge Code	NDG12556C
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

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]

Facility

$0.03

Service Code	NDC 58657-528-16
Hospital Charge Code	NDG12556
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]

Facility

$0.38

Service Code	NDC 68094-022-59
Hospital Charge Code	NDG12556C
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

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]

Facility

$0.03

Service Code	NDC 58657-528-16
Hospital Charge Code	NDG12556
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]

Facility

$0.38

Service Code	NDC 68094-022-59
Hospital Charge Code	NDG12556C
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

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]

Facility

$0.38

Service Code	NDC 68094-022-62
Hospital Charge Code	NDG12556C
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

DIPHENHYDRAMINE 25 MG CAPSULE [2509]

Facility

$0.06

Service Code	NDC 8770142982
Hospital Charge Code	1711311
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

DIPHENHYDRAMINE 25 MG CAPSULE [2509]

Facility

$0.06

Service Code	NDC 8770142982
Hospital Charge Code	1711311
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

DIPHENHYDRAMINE 25 MG CAPSULE [2509]

Facility

$0.06

Service Code	NDC 46122-440-78
Hospital Charge Code	1711311
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

DIPHENHYDRAMINE 25 MG CAPSULE [2509]

Facility

$0.06

Service Code	NDC 46122-440-78
Hospital Charge Code	1711311
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

DIPHENHYDRAMINE 25 MG CAPSULE [2509]

Facility

$0.05

Service Code	NDC 0904-7237-61
Hospital Charge Code	1711311
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

DIPHENHYDRAMINE 25 MG CAPSULE [2509]

Facility

$0.05

Service Code	NDC 0904-7237-61
Hospital Charge Code	1711311
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

DIPHENHYDRAMINE 25 MG TABLET [2505]

Facility

$0.05

Service Code	NDC 0904-5551-24
Hospital Charge Code	ERX2505
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

DIPHENHYDRAMINE 25 MG TABLET [2505]

Facility

$0.05

Service Code	NDC 0904-5551-24
Hospital Charge Code	ERX2505
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

DIPHENHYDRAMINE 50 MG CAPSULE [2510]

Facility

$0.03

Service Code	NDC 0904-5307-60
Hospital Charge Code	1711313
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

DIPHENHYDRAMINE 50 MG CAPSULE [2510]

Facility

$0.06

Service Code	NDC 0904-2056-61
Hospital Charge Code	1711313
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

DIPHENHYDRAMINE 50 MG CAPSULE [2510]

Facility

$0.03

Service Code	NDC 0904-5307-60
Hospital Charge Code	1711313
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

DIPHENHYDRAMINE 50 MG CAPSULE [2510]

Facility

$0.06

Service Code	NDC 0904-2056-61
Hospital Charge Code	1711313
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]

Facility

$3.61

Service Code	NDC 63323-664-01
Hospital Charge Code	1720312
Hospital Revenue Code	636
Min. Negotiated Rate	$1.99
Max. Negotiated Rate	$2.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.17
Rate for Payer: Aetna of CA Government/Medicare	$2.17
Rate for Payer: Cash Price	$1.62
Rate for Payer: Health Smart Auto/Commercial	$2.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.17
Rate for Payer: LLUH Dept of Risk Management WC	$1.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.71

DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]

Facility

$1.41

Service Code	NDC 0641-0376-21
Hospital Charge Code	1720312
Hospital Revenue Code	636
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.85
Rate for Payer: Aetna of CA Government/Medicare	$0.85
Rate for Payer: Cash Price	$0.63
Rate for Payer: Health Smart Auto/Commercial	$0.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.85
Rate for Payer: LLUH Dept of Risk Management WC	$0.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.06

DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]

Facility

$1.41

Service Code	NDC 0641-0376-21
Hospital Charge Code	1720312
Hospital Revenue Code	636
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.13
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cigna of CA HMO/PPO	$1.13
Rate for Payer: Health Smart Auto/Commercial	$0.85
Rate for Payer: LLUH Dept of Risk Management WC	$0.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.06

DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]

Facility

$3.61

Service Code	NDC 63323-664-01
Hospital Charge Code	1720312
Hospital Revenue Code	636
Min. Negotiated Rate	$1.99
Max. Negotiated Rate	$2.89
Rate for Payer: Cash Price	$1.62
Rate for Payer: Cigna of CA HMO/PPO	$2.89
Rate for Payer: Health Smart Auto/Commercial	$2.17
Rate for Payer: LLUH Dept of Risk Management WC	$1.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.71

DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]

Facility

$1.41

Service Code	NDC 0641-0376-25
Hospital Charge Code	1720312
Hospital Revenue Code	636
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.13
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cigna of CA HMO/PPO	$1.13
Rate for Payer: Health Smart Auto/Commercial	$0.85
Rate for Payer: LLUH Dept of Risk Management WC	$0.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.06

DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [2508]

Facility

$1.41

Service Code	NDC 0641-0376-25
Hospital Charge Code	1720312
Hospital Revenue Code	636
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.85
Rate for Payer: Aetna of CA Government/Medicare	$0.85
Rate for Payer: Cash Price	$0.63
Rate for Payer: Health Smart Auto/Commercial	$0.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.85
Rate for Payer: LLUH Dept of Risk Management WC	$0.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.06

Know your out-of-pocket cost for care.

All Charges