Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]

Facility

$0.22

Service Code	NDC 51672-2035-6
Hospital Charge Code	1743423
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]

Facility

$0.20

Service Code	NDC 24385-590-29
Hospital Charge Code	1743423
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

MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]

Facility

$0.22

Service Code	NDC 51672-2035-6
Hospital Charge Code	1743423
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

MICROFIBRILLAR COLLAGEN HEMOSTAT 8 CM X 6.25 CM X 1 CM SPONGE [33186]

Facility

$66.00

Service Code	NDC 53276-1050-03
Hospital Charge Code	1743684
Hospital Revenue Code	272
Min. Negotiated Rate	$36.30
Max. Negotiated Rate	$52.80
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna of CA HMO/PPO	$52.80
Rate for Payer: Health Smart Auto/Commercial	$39.60
Rate for Payer: LLUH Dept of Risk Management WC	$36.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.50

MICROFIBRILLAR COLLAGEN HEMOSTAT 8 CM X 6.25 CM X 1 CM SPONGE [33186]

Facility

$66.00

Service Code	NDC 53276-1050-03
Hospital Charge Code	1743684
Hospital Revenue Code	272
Min. Negotiated Rate	$36.30
Max. Negotiated Rate	$49.50
Rate for Payer: Health Smart Auto/Commercial	$39.60
Rate for Payer: Cash Price	$29.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.60
Rate for Payer: Aetna of CA Government/Medicare	$39.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.60
Rate for Payer: LLUH Dept of Risk Management WC	$36.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.50

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

Facility

$1.47

Service Code	NDC 68094-764-59
Hospital Charge Code	1730187
Hospital Revenue Code	259
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.10
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	$0.66
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 Beech St/Commercial/PHCS	$1.10

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

Facility

$1.47

Service Code	NDC 68094-764-62
Hospital Charge Code	1730187
Hospital Revenue Code	259
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.10
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	$0.66
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 Beech St/Commercial/PHCS	$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	1730187
Hospital Revenue Code	259
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.18
Rate for Payer: Cash Price	$0.66
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.10

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

Facility

$1.47

Service Code	NDC 68094-764-62
Hospital Charge Code	1730187
Hospital Revenue Code	259
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.18
Rate for Payer: Cash Price	$0.66
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.10

MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [213986]

Facility

$0.39

Service Code	CPT J2250
Hospital Charge Code	NDG213986A
Hospital Revenue Code	636
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.31
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.29

MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [213986]

Facility

$0.39

Service Code	CPT J2250
Hospital Charge Code	NDG213986A
Hospital Revenue Code	636
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.29
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	$0.18
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 Beech St/Commercial/PHCS	$0.29

MIDAZOLAM 1 MG/ML INJECTION SOLUTION [93519]

Facility

$0.38

Service Code	CPT J2250
Hospital Charge Code	1737056
Hospital Revenue Code	636
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of CA HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29

MIDAZOLAM 1 MG/ML INJECTION SOLUTION [93519]

Facility

$0.38

Service Code	CPT J2250
Hospital Charge Code	1737056
Hospital Revenue Code	636
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.29
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	$0.17
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 Beech St/Commercial/PHCS	$0.29

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

Facility

$0.33

Service Code	CPT J2250
Hospital Charge Code	1737047
Hospital Revenue Code	636
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

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

Facility

$0.39

Service Code	CPT J2250
Hospital Charge Code	1737056
Hospital Revenue Code	636
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
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: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cash Price	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.23
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: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29

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

Facility

$0.68

Service Code	CPT J2250
Hospital Charge Code	1737056
Hospital Revenue Code	636
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA HMO/PPO	$0.30
Rate for Payer: Cigna of CA HMO/PPO	$0.31
Rate for Payer: Cigna of CA HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cash Price	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.51

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

Facility

$0.33

Service Code	CPT J2250
Hospital Charge Code	1737047
Hospital Revenue Code	636
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]

Facility

$1.32

Service Code	NDC 0054-3566-99
Hospital Charge Code	NDG24176
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$0.99
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	$0.59
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 Beech St/Commercial/PHCS	$0.99

MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]

Facility

$1.32

Service Code	NDC 0054-3566-99
Hospital Charge Code	NDG24176
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Cash Price	$0.59
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$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	ERX222178
Hospital Revenue Code	259
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$15.75
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	$9.45
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 Beech St/Commercial/PHCS	$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	ERX222178
Hospital Revenue Code	259
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$16.80
Rate for Payer: Cash Price	$9.45
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$15.75

MIDAZOLAM 5 MG/ML INJECTION. [40810608]

Facility

$0.74

Service Code	CPT J2250
Hospital Charge Code	1737042
Hospital Revenue Code	636
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.56
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	$0.33
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	$0.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.56

MIDAZOLAM 5 MG/ML INJECTION. [40810608]

Facility

$3.64

Service Code	CPT J2250
Hospital Charge Code	1758498
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.64
Rate for Payer: Cash Price	$0.37
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cash Price	$0.62
Rate for Payer: Cigna of CA HMO/PPO	$2.91
Rate for Payer: Cigna of CA HMO/PPO	$0.66
Rate for Payer: Cigna of CA HMO/PPO	$1.10
Rate for Payer: Cigna of CA HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$2.18
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.83
Rate for Payer: LLUH Dept of Risk Management WC	$2.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.04

MIDAZOLAM 5 MG/ML INJECTION. [40810608]

Facility

$1.27

Service Code	CPT J2250
Hospital Charge Code	1737045
Hospital Revenue Code	636
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Cash Price	$0.57
Rate for Payer: Cigna of CA HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.95

MIDAZOLAM 5 MG/ML INJECTION. [40810608]

Facility

$0.74

Service Code	CPT J2250
Hospital Charge Code	1737042
Hospital Revenue Code	636
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.59
Rate for Payer: Cash Price	$0.33
Rate for Payer: Cigna of CA HMO/PPO	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.56

Know your out-of-pocket cost for care.

All Charges