Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [9828]

Facility

$0.66

Service Code	NDC 0270-0445-40
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.53
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.50

DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [9828]

Facility

$0.66

Service Code	NDC 0270-0445-40
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.50

DIAZEPAM 10 MG TABLET [2403]

Facility

$0.12

Service Code	NDC 0378-0477-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

DIAZEPAM 10 MG TABLET [2403]

Facility

$0.09

Service Code	NDC 51079-286-01
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

DIAZEPAM 10 MG TABLET [2403]

Facility

$0.09

Service Code	NDC 51079-286-20
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

DIAZEPAM 10 MG TABLET [2403]

Facility

$0.12

Service Code	NDC 0378-0477-01
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	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

DIAZEPAM 10 MG TABLET [2403]

Facility

$0.09

Service Code	NDC 51079-286-01
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

DIAZEPAM 10 MG TABLET [2403]

Facility

$0.09

Service Code	NDC 51079-286-20
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

DIAZEPAM 2 MG TABLET [2404]

Facility

$0.08

Service Code	NDC 51079-284-20
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

DIAZEPAM 2 MG TABLET [2404]

Facility

$0.08

Service Code	NDC 51079-284-01
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

DIAZEPAM 2 MG TABLET [2404]

Facility

$0.08

Service Code	NDC 51079-284-20
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

DIAZEPAM 2 MG TABLET [2404]

Facility

$0.08

Service Code	NDC 51079-284-01
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

DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION [154274]

Facility

$0.92

Service Code	NDC 68094-750-62
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.74
Rate for Payer: Cash Price	$0.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.74
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: Multiplan Commercial	$0.69

DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION [154274]

Facility

$0.92

Service Code	NDC 68094-750-62
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.55
Rate for Payer: Aetna of CA Government/Medicare	$0.55
Rate for Payer: Cash Price	$0.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.74
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: Multiplan Commercial	$0.69

DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION [154274]

Facility

$0.92

Service Code	NDC 68094-750-59
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.74
Rate for Payer: Cash Price	$0.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.74
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: Multiplan Commercial	$0.69

DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION [154274]

Facility

$0.92

Service Code	NDC 68094-750-59
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.55
Rate for Payer: Aetna of CA Government/Medicare	$0.55
Rate for Payer: Cash Price	$0.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.74
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: Multiplan Commercial	$0.69

DIAZEPAM 5 MG/5 ML (1 MG/ML) ORAL SOLUTION [2402]

Facility

$0.14

Service Code	NDC 0054-3188-63
Hospital Charge Code	901700029
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	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
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 Commercial	$0.11

DIAZEPAM 5 MG/5 ML (1 MG/ML) ORAL SOLUTION [2402]

Facility

$0.14

Service Code	NDC 0054-3188-63
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.11

DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]

Facility

$14.77

Service Code	HCPCS J3360
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.12
Max. Negotiated Rate	$11.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.86
Rate for Payer: Aetna of CA Government/Medicare	$8.86
Rate for Payer: Aetna of CA Government/Medicare	$8.86
Rate for Payer: Cash Price	$8.12
Rate for Payer: Cash Price	$8.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.81
Rate for Payer: Health Smart Auto/Commercial	$8.86
Rate for Payer: Health Smart Auto/Commercial	$8.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.86
Rate for Payer: LLUH Dept of Risk Management WC	$8.12
Rate for Payer: LLUH Dept of Risk Management WC	$8.12
Rate for Payer: Multiplan Commercial	$11.08
Rate for Payer: Multiplan Commercial	$11.07

DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]

Facility

$14.76

Service Code	HCPCS J3360
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.12
Max. Negotiated Rate	$11.81
Rate for Payer: Cash Price	$8.12
Rate for Payer: Cash Price	$8.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.81
Rate for Payer: Health Smart Auto/Commercial	$8.86
Rate for Payer: Health Smart Auto/Commercial	$8.86
Rate for Payer: LLUH Dept of Risk Management WC	$8.12
Rate for Payer: LLUH Dept of Risk Management WC	$8.12
Rate for Payer: Multiplan Commercial	$11.07
Rate for Payer: Multiplan Commercial	$11.08

DIAZEPAM 5 MG TABLET [2405]

Facility

$0.08

Service Code	NDC 51079-285-20
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

DIAZEPAM 5 MG TABLET [2405]

Facility

$0.08

Service Code	NDC 51079-285-20
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

DIAZEPAM 5 MG TABLET [2405]

Facility

$0.08

Service Code	NDC 51079-285-01
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

DIAZEPAM 5 MG TABLET [2405]

Facility

$0.08

Service Code	NDC 51079-285-01
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

DIAZOXIDE 50 MG/ML ORAL SUSPENSION [19713]

Facility

$12.38

Service Code	NDC 13517-100-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.81
Max. Negotiated Rate	$9.90
Rate for Payer: Cash Price	$6.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.90
Rate for Payer: Health Smart Auto/Commercial	$7.43
Rate for Payer: LLUH Dept of Risk Management WC	$6.81
Rate for Payer: Multiplan Commercial	$9.29

Know your out-of-pocket cost for care.

All Charges