Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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 63323-664-00
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-ZINC ACETATE 1 %-0.1 % TOPICAL CREAM [22409]

Facility

$0.13

Service Code	NDC 58232-07401
Hospital Charge Code	1743032
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

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

Facility

$0.15

Service Code	NDC 1254717162
Hospital Charge Code	1743032
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

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

Facility

$0.13

Service Code	NDC 58232-07401
Hospital Charge Code	1743032
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	$0.06
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	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

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

Facility

$0.15

Service Code	NDC 1254717162
Hospital Charge Code	1743032
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

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

Facility

$0.09

Service Code	NDC 24385-210-03
Hospital Charge Code	1743710
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.07

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

Facility

$0.08

Service Code	NDC 0904-5354-31
Hospital Charge Code	1743710
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

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

Facility

$0.09

Service Code	NDC 45802-358-03
Hospital Charge Code	1743710
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	$0.04
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	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

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

Facility

$0.09

Service Code	NDC 24385-210-03
Hospital Charge Code	1743710
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	$0.04
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	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

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

Facility

$0.16

Service Code	NDC 1254717167
Hospital Charge Code	NDG16299
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

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

Facility

$0.16

Service Code	NDC 1254717167
Hospital Charge Code	NDG16299
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

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

Facility

$0.08

Service Code	NDC 0904-5354-31
Hospital Charge Code	1743710
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

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

Facility

$0.09

Service Code	NDC 45802-358-03
Hospital Charge Code	1743710
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.07

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

Facility

$1.40

Service Code	NDC 9999-2515-01
Hospital Charge Code	NDG2515
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.12
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.05

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

Facility

$1.40

Service Code	NDC 0054-3194-46
Hospital Charge Code	1715914
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.05
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	$0.63
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 Beech St/Commercial/PHCS	$1.05

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

Facility

$1.40

Service Code	NDC 0054-3194-46
Hospital Charge Code	1715914
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.12
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.05

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

Facility

$1.40

Service Code	NDC 9999-2515-01
Hospital Charge Code	NDG2515
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.05
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	$0.63
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 Beech St/Commercial/PHCS	$1.05

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

Facility

$0.49

Service Code	NDC 59762-1061-1
Hospital Charge Code	1730124
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.37

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

Facility

$0.49

Service Code	NDC 59762-1061-1
Hospital Charge Code	1730124
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.37
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	$0.22
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 Beech St/Commercial/PHCS	$0.37

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

Facility

$0.56

Service Code	NDC 69315-910-01
Hospital Charge Code	1730124
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.45
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.42

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

Facility

$0.20

Service Code	NDC 62559-490-01
Hospital Charge Code	1730124
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.15

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

Facility

$0.56

Service Code	NDC 69315-910-01
Hospital Charge Code	1730124
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.42
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	$0.25
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 Beech St/Commercial/PHCS	$0.42

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

Facility

$0.23

Service Code	NDC 0406-1236-01
Hospital Charge Code	1730124
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.17
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	$0.10
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	$0.17

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

Facility

$0.20

Service Code	NDC 62559-490-01
Hospital Charge Code	1730124
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.15
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	$0.09
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 Beech St/Commercial/PHCS	$0.15

Know your out-of-pocket cost for care.

All Charges