Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP [121529]

Facility

$1.47

Service Code	NDC 68094-764-62
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.88
Rate for Payer: Aetna of CA Government/Medicare	$0.88
Rate for Payer: Cash Price	$0.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.18
Rate for Payer: Health Smart Auto/Commercial	$0.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.88
Rate for Payer: LLUH Dept of Risk Management WC	$0.81
Rate for Payer: Multiplan Commercial	$1.10

MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP [121529]

Facility

$1.47

Service Code	NDC 68094-764-59
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.88
Rate for Payer: Aetna of CA Government/Medicare	$0.88
Rate for Payer: Cash Price	$0.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.18
Rate for Payer: Health Smart Auto/Commercial	$0.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.88
Rate for Payer: LLUH Dept of Risk Management WC	$0.81
Rate for Payer: Multiplan Commercial	$1.10

MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP [121529]

Facility

$1.47

Service Code	NDC 68094-764-59
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.18
Rate for Payer: Cash Price	$0.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.18
Rate for Payer: Health Smart Auto/Commercial	$0.88
Rate for Payer: LLUH Dept of Risk Management WC	$0.81
Rate for Payer: Multiplan Commercial	$1.10

MIDAZOLAM 1 MG/ML INJECTION SOLUTION (PF/NON-PF WRAP) [40893519]

Facility

$0.39

Service Code	HCPCS J2250
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.31
Rate for Payer: Cash Price	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.29

MIDAZOLAM 1 MG/ML INJECTION SOLUTION (PF/NON-PF WRAP) [40893519]

Facility

$0.39

Service Code	HCPCS J2250
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.31
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	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.31
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 Commercial	$0.29

MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]

Facility

$1.32

Service Code	NDC 0054-3566-99
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$0.99

MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]

Facility

$1.32

Service Code	NDC 0054-3566-99
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$0.99

MIDAZOLAM 3 MG-KETAMINE 25 MG-ONDANSETRON 2 MG SUBLINGUAL TROCHE [222178]

Facility

$21.00

Service Code	NDC 71384-630-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$16.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.60
Rate for Payer: Aetna of CA Government/Medicare	$12.60
Rate for Payer: Cash Price	$11.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.80
Rate for Payer: Health Smart Auto/Commercial	$12.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.60
Rate for Payer: LLUH Dept of Risk Management WC	$11.55
Rate for Payer: Multiplan Commercial	$15.75

MIDAZOLAM 3 MG-KETAMINE 25 MG-ONDANSETRON 2 MG SUBLINGUAL TROCHE [222178]

Facility

$21.00

Service Code	NDC 71384-630-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$16.80
Rate for Payer: Cash Price	$11.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.80
Rate for Payer: Health Smart Auto/Commercial	$12.60
Rate for Payer: LLUH Dept of Risk Management WC	$11.55
Rate for Payer: Multiplan Commercial	$15.75

MIDAZOLAM 5 MG/ML INJECTION. [40810608]

Facility

$1.39

Service Code	HCPCS J2252
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.83
Rate for Payer: Aetna of CA Government/Medicare	$0.83
Rate for Payer: Cash Price	$0.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.11
Rate for Payer: Health Smart Auto/Commercial	$0.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.83
Rate for Payer: LLUH Dept of Risk Management WC	$0.76
Rate for Payer: Multiplan Commercial	$1.04

MIDAZOLAM 5 MG/ML INJECTION. [40810608]

Facility

$1.39

Service Code	HCPCS J2252
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.11
Rate for Payer: Cash Price	$0.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.11
Rate for Payer: Health Smart Auto/Commercial	$0.83
Rate for Payer: LLUH Dept of Risk Management WC	$0.76
Rate for Payer: Multiplan Commercial	$1.04

MIDAZOLAM 5 MG/ML INJECTION. [40810608]

Facility

$0.83

Service Code	HCPCS J2250
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.27
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cash Price	$0.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Commercial	$0.52
Rate for Payer: Multiplan Commercial	$0.34
Rate for Payer: Multiplan Commercial	$0.62

MIDAZOLAM 5 MG/ML INJECTION. [40810608]

Facility

$0.45

Service Code	HCPCS J2250
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cash Price	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Commercial	$0.62
Rate for Payer: Multiplan Commercial	$0.52
Rate for Payer: Multiplan Commercial	$0.34

MIDAZOLAM 5 MG/ML INJECTION SOLUTION [10608]

Facility

$0.45

Service Code	HCPCS J2250
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.27
Rate for Payer: Aetna of CA Government/Medicare	$0.27
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.34

MIDAZOLAM 5 MG/ML INJECTION SOLUTION [10608]

Facility

$0.45

Service Code	HCPCS J2250
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.34

MIDAZOLAM 5 MG/ML INTRANASAL (KIT) WITH A MUCOSAL ATOMIZER (MAD) DEVICE [4081775]

Facility

$0.73

Service Code	NDC 9994-1817-75
Hospital Charge Code	901700004
Hospital Revenue Code	250
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

MIDAZOLAM 5 MG/ML INTRANASAL (KIT) WITH A MUCOSAL ATOMIZER (MAD) DEVICE [4081775]

Facility

$0.73

Service Code	NDC 9994-1817-75
Hospital Charge Code	901700004
Hospital Revenue Code	250
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

MIDAZOLAM CONTINUOUS INFUSION (STRAIGHT DRUG) 5 MG/ML [4081034]

Facility

$0.83

Service Code	HCPCS J2250
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.49
Rate for Payer: Aetna of CA Government/Medicare	$2.49
Rate for Payer: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$2.32
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cash Price	$2.28
Rate for Payer: Cash Price	$0.50
Rate for Payer: Cash Price	$2.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.32
Rate for Payer: Health Smart Auto/Commercial	$2.49
Rate for Payer: Health Smart Auto/Commercial	$2.32
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$2.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: LLUH Dept of Risk Management WC	$2.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68
Rate for Payer: Multiplan Commercial	$2.90
Rate for Payer: Multiplan Commercial	$3.11
Rate for Payer: Multiplan Commercial	$0.62

MIDAZOLAM CONTINUOUS INFUSION (STRAIGHT DRUG) 5 MG/ML [4081034]

Facility

$4.15

Service Code	HCPCS J2250
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$3.32
Rate for Payer: Cash Price	$2.28
Rate for Payer: Cash Price	$2.12
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.66
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Health Smart Auto/Commercial	$2.49
Rate for Payer: Health Smart Auto/Commercial	$2.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: LLUH Dept of Risk Management WC	$2.28
Rate for Payer: LLUH Dept of Risk Management WC	$2.12
Rate for Payer: Multiplan Commercial	$3.11
Rate for Payer: Multiplan Commercial	$0.62
Rate for Payer: Multiplan Commercial	$0.68
Rate for Payer: Multiplan Commercial	$2.90

MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [211683]

Facility

$0.31

Service Code	HCPCS J2250
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27
Rate for Payer: Multiplan Commercial	$0.23

MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [211683]

Facility

$0.36

Service Code	HCPCS J2250
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.23
Rate for Payer: Multiplan Commercial	$0.27

MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [211683]

Facility

$0.36

Service Code	HCPCS J2251
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [211683]

Facility

$0.36

Service Code	HCPCS J2251
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION [204176]

Facility

$1.39

Service Code	HCPCS J2252
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.11
Rate for Payer: Cash Price	$0.77
Rate for Payer: Cash Price	$0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.11
Rate for Payer: Health Smart Auto/Commercial	$0.83
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.76
Rate for Payer: Multiplan Commercial	$0.61
Rate for Payer: Multiplan Commercial	$1.04

MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION [204176]

Facility

$0.81

Service Code	HCPCS J2252
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.83
Rate for Payer: Aetna of CA Government/Medicare	$0.83
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.77
Rate for Payer: Cash Price	$0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.11
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.83
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.76
Rate for Payer: Multiplan Commercial	$1.04
Rate for Payer: Multiplan Commercial	$0.61

Know your out-of-pocket cost for care.

All Charges