Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DIAZEPAM 10 MG TABLET [2403]

Facility

$0.09

Service Code	NDC 51079-286-01
Hospital Charge Code	1730082
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

DIAZEPAM 10 MG TABLET [2403]

Facility

$0.12

Service Code	NDC 0378-0477-01
Hospital Charge Code	1730082
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.09

DIAZEPAM 10 MG TABLET [2403]

Facility

$0.12

Service Code	NDC 0378-0477-01
Hospital Charge Code	1730082
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.09
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	$0.05
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 Beech St/Commercial/PHCS	$0.09

DIAZEPAM 10 MG TABLET [2403]

Facility

$0.09

Service Code	NDC 51079-286-20
Hospital Charge Code	1730082
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

DIAZEPAM 10 MG TABLET [2403]

Facility

$0.09

Service Code	NDC 51079-286-01
Hospital Charge Code	1730082
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

DIAZEPAM 12.5 MG-15 MG-17.5 MG-20 MG RECTAL KIT [87869]

Facility

$420.90

Service Code	NDC 0187-0659-20
Hospital Charge Code	ERX87869
Hospital Revenue Code	259
Min. Negotiated Rate	$231.50
Max. Negotiated Rate	$315.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$252.54
Rate for Payer: Aetna of CA Government/Medicare	$252.54
Rate for Payer: Cash Price	$189.41
Rate for Payer: Health Smart Auto/Commercial	$252.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$252.54
Rate for Payer: LLUH Dept of Risk Management WC	$231.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$315.68

DIAZEPAM 12.5 MG-15 MG-17.5 MG-20 MG RECTAL KIT [87869]

Facility

$420.90

Service Code	NDC 0187-0659-20
Hospital Charge Code	ERX87869
Hospital Revenue Code	259
Min. Negotiated Rate	$231.50
Max. Negotiated Rate	$336.72
Rate for Payer: Cash Price	$189.41
Rate for Payer: Cigna of CA HMO/PPO	$336.72
Rate for Payer: Health Smart Auto/Commercial	$252.54
Rate for Payer: LLUH Dept of Risk Management WC	$231.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$315.68

DIAZEPAM 2.5 MG RECTAL KIT [87865]

Facility

$354.82

Service Code	NDC 66490-650-20
Hospital Charge Code	1748085
Hospital Revenue Code	259
Min. Negotiated Rate	$195.15
Max. Negotiated Rate	$266.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$212.89
Rate for Payer: Aetna of CA Government/Medicare	$212.89
Rate for Payer: Cash Price	$159.67
Rate for Payer: Health Smart Auto/Commercial	$212.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$212.89
Rate for Payer: LLUH Dept of Risk Management WC	$195.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$266.12

DIAZEPAM 2.5 MG RECTAL KIT [87865]

Facility

$354.82

Service Code	NDC 66490-650-20
Hospital Charge Code	1748085
Hospital Revenue Code	259
Min. Negotiated Rate	$195.15
Max. Negotiated Rate	$283.86
Rate for Payer: Cash Price	$159.67
Rate for Payer: Cigna of CA HMO/PPO	$283.86
Rate for Payer: Health Smart Auto/Commercial	$212.89
Rate for Payer: LLUH Dept of Risk Management WC	$195.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$266.12

DIAZEPAM 2 MG TABLET [2404]

Facility

$0.08

Service Code	NDC 51079-284-20
Hospital Charge Code	1730080
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

DIAZEPAM 2 MG TABLET [2404]

Facility

$0.08

Service Code	NDC 51079-284-20
Hospital Charge Code	1730080
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

DIAZEPAM 2 MG TABLET [2404]

Facility

$0.08

Service Code	NDC 51079-284-01
Hospital Charge Code	1730080
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

DIAZEPAM 2 MG TABLET [2404]

Facility

$0.08

Service Code	NDC 51079-284-01
Hospital Charge Code	1730080
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

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	NDG154274
Hospital Revenue Code	259
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.69
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	$0.41
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 Beech St/Commercial/PHCS	$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	NDG154274
Hospital Revenue Code	259
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.69
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	$0.41
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 Beech St/Commercial/PHCS	$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	NDG154274
Hospital Revenue Code	259
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.74
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$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	NDG154274
Hospital Revenue Code	259
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.74
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$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	1715521
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$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	1715521
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	$0.06
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	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT [87867]

Facility

$420.90

Service Code	NDC 0187-0658-20
Hospital Charge Code	1748083
Hospital Revenue Code	259
Min. Negotiated Rate	$231.50
Max. Negotiated Rate	$315.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$252.54
Rate for Payer: Aetna of CA Government/Medicare	$252.54
Rate for Payer: Cash Price	$189.41
Rate for Payer: Health Smart Auto/Commercial	$252.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$252.54
Rate for Payer: LLUH Dept of Risk Management WC	$231.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$315.68

DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT [87867]

Facility

$420.90

Service Code	NDC 0187-0658-20
Hospital Charge Code	1748083
Hospital Revenue Code	259
Min. Negotiated Rate	$231.50
Max. Negotiated Rate	$336.72
Rate for Payer: Cash Price	$189.41
Rate for Payer: Cigna of CA HMO/PPO	$336.72
Rate for Payer: Health Smart Auto/Commercial	$252.54
Rate for Payer: LLUH Dept of Risk Management WC	$231.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$315.68

DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]

Facility

$20.20

Service Code	CPT J3360
Hospital Charge Code	1737041
Hospital Revenue Code	636
Min. Negotiated Rate	$11.11
Max. Negotiated Rate	$15.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.12
Rate for Payer: Aetna of CA Government/Medicare	$12.12
Rate for Payer: Cash Price	$9.09
Rate for Payer: Health Smart Auto/Commercial	$12.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.12
Rate for Payer: LLUH Dept of Risk Management WC	$11.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.15

DIAZEPAM 5 MG/ML INJECTION SYRINGE [106278]

Facility

$20.20

Service Code	CPT J3360
Hospital Charge Code	1737041
Hospital Revenue Code	636
Min. Negotiated Rate	$11.11
Max. Negotiated Rate	$16.16
Rate for Payer: Cash Price	$9.09
Rate for Payer: Cigna of CA HMO/PPO	$16.16
Rate for Payer: Health Smart Auto/Commercial	$12.12
Rate for Payer: LLUH Dept of Risk Management WC	$11.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.15

DIAZEPAM 5 MG TABLET [2405]

Facility

$0.08

Service Code	NDC 51079-285-01
Hospital Charge Code	1730081
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

DIAZEPAM 5 MG TABLET [2405]

Facility

$0.08

Service Code	NDC 51079-285-20
Hospital Charge Code	1730081
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

Know your out-of-pocket cost for care.

All Charges