Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR [29276]

Facility

$0.73

Service Code	NDC 50742-251-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.55

DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR [29276]

Facility

$0.95

Service Code	NDC 63304-721-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.76
Rate for Payer: Cash Price	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.76
Rate for Payer: Health Smart Auto/Commercial	$0.57
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Commercial	$0.71

DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR [29276]

Facility

$0.95

Service Code	NDC 63304-721-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.57
Rate for Payer: Aetna of CA Government/Medicare	$0.57
Rate for Payer: Cash Price	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.76
Rate for Payer: Health Smart Auto/Commercial	$0.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.57
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Commercial	$0.71

DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR [29276]

Facility

$0.73

Service Code	NDC 50742-251-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.55

DILTIAZEM CD 360 MG CAPSULE,EXTENDED RELEASE 24 HR [29278]

Facility

$5.87

Service Code	NDC 47335-679-81
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.23
Max. Negotiated Rate	$4.70
Rate for Payer: Cash Price	$3.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.70
Rate for Payer: Health Smart Auto/Commercial	$3.52
Rate for Payer: LLUH Dept of Risk Management WC	$3.23
Rate for Payer: Multiplan Commercial	$4.40

DILTIAZEM CD 360 MG CAPSULE,EXTENDED RELEASE 24 HR [29278]

Facility

$0.48

Service Code	NDC 50742-252-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.36

DILTIAZEM CD 360 MG CAPSULE,EXTENDED RELEASE 24 HR [29278]

Facility

$5.87

Service Code	NDC 47335-679-81
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.23
Max. Negotiated Rate	$4.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.52
Rate for Payer: Aetna of CA Government/Medicare	$3.52
Rate for Payer: Cash Price	$3.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.70
Rate for Payer: Health Smart Auto/Commercial	$3.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.52
Rate for Payer: LLUH Dept of Risk Management WC	$3.23
Rate for Payer: Multiplan Commercial	$4.40

DILTIAZEM CD 360 MG CAPSULE,EXTENDED RELEASE 24 HR [29278]

Facility

$0.48

Service Code	NDC 50742-252-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
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	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
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	$0.26
Rate for Payer: Multiplan Commercial	$0.36

DILTIAZEM ER 120 MG TABLET,EXTENDED RELEASE 24 HR [35177]

Facility

$2.70

Service Code	NDC 69097-992-02
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$2.16
Rate for Payer: Cash Price	$1.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.16
Rate for Payer: Health Smart Auto/Commercial	$1.62
Rate for Payer: LLUH Dept of Risk Management WC	$1.49
Rate for Payer: Multiplan Commercial	$2.02

DILTIAZEM ER 120 MG TABLET,EXTENDED RELEASE 24 HR [35177]

Facility

$2.70

Service Code	NDC 69097-992-02
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$2.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.62
Rate for Payer: Aetna of CA Government/Medicare	$1.62
Rate for Payer: Cash Price	$1.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.16
Rate for Payer: Health Smart Auto/Commercial	$1.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.62
Rate for Payer: LLUH Dept of Risk Management WC	$1.49
Rate for Payer: Multiplan Commercial	$2.02

DILTIAZEM ER 240 MG CAPSULE,24 HR,EXTENDED RELEASE [29273]

Facility

$1.28

Service Code	NDC 68682-369-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Cash Price	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Commercial	$0.96

DILTIAZEM ER 240 MG CAPSULE,24 HR,EXTENDED RELEASE [29273]

Facility

$1.28

Service Code	NDC 68682-369-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.77
Rate for Payer: Aetna of CA Government/Medicare	$0.77
Rate for Payer: Cash Price	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Commercial	$0.96

DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [14100]

Facility

$3.97

Service Code	NDC 51079-924-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.38
Rate for Payer: Aetna of CA Government/Medicare	$2.38
Rate for Payer: Cash Price	$2.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$2.98

DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [14100]

Facility

$3.04

Service Code	NDC 0378-6060-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$2.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.82
Rate for Payer: Aetna of CA Government/Medicare	$1.82
Rate for Payer: Cash Price	$1.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.43
Rate for Payer: Health Smart Auto/Commercial	$1.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$1.67
Rate for Payer: Multiplan Commercial	$2.28

DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [14100]

Facility

$3.32

Service Code	NDC 68462-850-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$2.66
Rate for Payer: Cash Price	$1.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.66
Rate for Payer: Health Smart Auto/Commercial	$1.99
Rate for Payer: LLUH Dept of Risk Management WC	$1.83
Rate for Payer: Multiplan Commercial	$2.49

DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [14100]

Facility

$3.04

Service Code	NDC 0378-6060-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$2.43
Rate for Payer: Cash Price	$1.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.43
Rate for Payer: Health Smart Auto/Commercial	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$1.67
Rate for Payer: Multiplan Commercial	$2.28

DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [14100]

Facility

$3.97

Service Code	NDC 51079-924-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Cash Price	$2.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$2.98

DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [14100]

Facility

$3.32

Service Code	NDC 68462-850-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$2.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.99
Rate for Payer: Aetna of CA Government/Medicare	$1.99
Rate for Payer: Cash Price	$1.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.66
Rate for Payer: Health Smart Auto/Commercial	$1.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.99
Rate for Payer: LLUH Dept of Risk Management WC	$1.83
Rate for Payer: Multiplan Commercial	$2.49

DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [14100]

Facility

$3.97

Service Code	NDC 51079-924-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.38
Rate for Payer: Aetna of CA Government/Medicare	$2.38
Rate for Payer: Cash Price	$2.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$2.98

DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR [14100]

Facility

$3.97

Service Code	NDC 51079-924-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Cash Price	$2.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$2.98

DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]

Facility

$4.67

Service Code	NDC 51079-925-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$3.74
Rate for Payer: Cash Price	$2.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.74
Rate for Payer: Health Smart Auto/Commercial	$2.80
Rate for Payer: LLUH Dept of Risk Management WC	$2.57
Rate for Payer: Multiplan Commercial	$3.50

DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]

Facility

$4.67

Service Code	NDC 51079-925-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$3.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.80
Rate for Payer: Aetna of CA Government/Medicare	$2.80
Rate for Payer: Cash Price	$2.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.74
Rate for Payer: Health Smart Auto/Commercial	$2.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.80
Rate for Payer: LLUH Dept of Risk Management WC	$2.57
Rate for Payer: Multiplan Commercial	$3.50

DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]

Facility

$4.67

Service Code	NDC 51079-925-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$3.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.80
Rate for Payer: Aetna of CA Government/Medicare	$2.80
Rate for Payer: Cash Price	$2.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.74
Rate for Payer: Health Smart Auto/Commercial	$2.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.80
Rate for Payer: LLUH Dept of Risk Management WC	$2.57
Rate for Payer: Multiplan Commercial	$3.50

DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]

Facility

$3.79

Service Code	NDC 68462-851-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.08
Max. Negotiated Rate	$3.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.27
Rate for Payer: Aetna of CA Government/Medicare	$2.27
Rate for Payer: Cash Price	$2.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.03
Rate for Payer: Health Smart Auto/Commercial	$2.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.27
Rate for Payer: LLUH Dept of Risk Management WC	$2.08
Rate for Payer: Multiplan Commercial	$2.84

DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]

Facility

$3.48

Service Code	NDC 0378-6090-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$2.78
Rate for Payer: Cash Price	$1.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.78
Rate for Payer: Health Smart Auto/Commercial	$2.09
Rate for Payer: LLUH Dept of Risk Management WC	$1.91
Rate for Payer: Multiplan Commercial	$2.61

Know your out-of-pocket cost for care.

All Charges