Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC PET TUMOR LIMITED

Facility

$9,459.00

Service Code	CPT 78811 TC
Hospital Charge Code	909301480
Hospital Revenue Code	409
Min. Negotiated Rate	$5,202.45
Max. Negotiated Rate	$7,567.20
Rate for Payer: Cash Price	$4,256.55
Rate for Payer: Cigna of CA HMO/PPO	$7,567.20
Rate for Payer: Health Smart Auto/Commercial	$5,675.40
Rate for Payer: LLUH Dept of Risk Management WC	$5,202.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7,094.25

HC PET TUMOR LIMITED

Facility

$9,459.00

Service Code	CPT 78811 TC
Hospital Charge Code	909301480
Hospital Revenue Code	409
Min. Negotiated Rate	$5,202.45
Max. Negotiated Rate	$7,094.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5,675.40
Rate for Payer: Aetna of CA Government/Medicare	$5,675.40
Rate for Payer: Cash Price	$4,256.55
Rate for Payer: Health Smart Auto/Commercial	$5,675.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5,675.40
Rate for Payer: LLUH Dept of Risk Management WC	$5,202.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7,094.25

HC PHARM-CHLORIDE IV SOLUTION

Facility

$24.00

Hospital Charge Code	900912107
Hospital Revenue Code	301
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$19.20
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna of CA HMO/PPO	$19.20
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.00

HC PHARM-CHLORIDE IV SOLUTION

Facility

$20.00

Hospital Charge Code	900912107
Hospital Revenue Code	301
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.00
Rate for Payer: Aetna of CA Government/Medicare	$12.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.00

HC PHARM-GLUCOSE IV SOLUTION

Facility

$17.00

Service Code	CPT 81099
Hospital Charge Code	900912109
Hospital Revenue Code	301
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$12.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.20
Rate for Payer: Aetna of CA Government/Medicare	$10.20
Rate for Payer: Cash Price	$7.65
Rate for Payer: Health Smart Auto/Commercial	$10.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.20
Rate for Payer: LLUH Dept of Risk Management WC	$9.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.75

HC PHARM-GLUCOSE IV SOLUTION

Facility

$24.00

Service Code	CPT 81099
Hospital Charge Code	900912109
Hospital Revenue Code	301
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$19.20
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna of CA HMO/PPO	$19.20
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.00

HC PHARM-PHOSPHORUS IV SOLUTION

Facility

$24.00

Hospital Charge Code	900912108
Hospital Revenue Code	301
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$19.20
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna of CA HMO/PPO	$19.20
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.00

HC PHARM-PHOSPHORUS IV SOLUTION

Facility

$20.00

Hospital Charge Code	900912108
Hospital Revenue Code	301
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.00
Rate for Payer: Aetna of CA Government/Medicare	$12.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.00

HC PHARM-POTASSIUM IV SOLUTION

Facility

$20.00

Hospital Charge Code	900912106
Hospital Revenue Code	301
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.00
Rate for Payer: Aetna of CA Government/Medicare	$12.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.00

HC PHARM-POTASSIUM IV SOLUTION

Facility

$24.00

Hospital Charge Code	900912106
Hospital Revenue Code	301
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$19.20
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna of CA HMO/PPO	$19.20
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.00

HC PHARM-SODIUM IV SOLUTION

Facility

$20.00

Hospital Charge Code	900912105
Hospital Revenue Code	301
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.00
Rate for Payer: Aetna of CA Government/Medicare	$12.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.00

HC PHARM-SODIUM IV SOLUTION

Facility

$24.00

Hospital Charge Code	900912105
Hospital Revenue Code	301
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$19.20
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna of CA HMO/PPO	$19.20
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.00

HC PH BODY FLUID

Facility

$150.00

Service Code	CPT 83986
Hospital Charge Code	900910261
Hospital Revenue Code	301
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$120.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna of CA HMO/PPO	$120.00
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$112.50

HC PH BODY FLUID

Facility

$13.00

Service Code	CPT 83986
Hospital Charge Code	900910261
Hospital Revenue Code	301
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$9.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.80
Rate for Payer: Aetna of CA Government/Medicare	$7.80
Rate for Payer: Cash Price	$5.85
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.75

HC PHENCYCLIDINE CONF

Facility

$225.00

Service Code	CPT 83992
Hospital Charge Code	900910517
Hospital Revenue Code	301
Min. Negotiated Rate	$123.75
Max. Negotiated Rate	$168.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$135.00
Rate for Payer: Aetna of CA Government/Medicare	$135.00
Rate for Payer: Cash Price	$101.25
Rate for Payer: Health Smart Auto/Commercial	$135.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$135.00
Rate for Payer: LLUH Dept of Risk Management WC	$123.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$168.75

HC PHENCYCLIDINE CONF

Facility

$271.00

Service Code	CPT G0480
Hospital Charge Code	900910517
Hospital Revenue Code	301
Min. Negotiated Rate	$149.05
Max. Negotiated Rate	$216.80
Rate for Payer: Cash Price	$121.95
Rate for Payer: Cigna of CA HMO/PPO	$216.80
Rate for Payer: Health Smart Auto/Commercial	$162.60
Rate for Payer: LLUH Dept of Risk Management WC	$149.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$203.25

HC PHENCYCLIDINE CONF

Facility

$271.00

Service Code	CPT 83992
Hospital Charge Code	900910517
Hospital Revenue Code	301
Min. Negotiated Rate	$149.05
Max. Negotiated Rate	$216.80
Rate for Payer: Cash Price	$121.95
Rate for Payer: Cigna of CA HMO/PPO	$216.80
Rate for Payer: Health Smart Auto/Commercial	$162.60
Rate for Payer: LLUH Dept of Risk Management WC	$149.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$203.25

HC PHENCYCLIDINE CONF

Facility

$225.00

Service Code	CPT G0480
Hospital Charge Code	900910517
Hospital Revenue Code	301
Min. Negotiated Rate	$123.75
Max. Negotiated Rate	$168.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$135.00
Rate for Payer: Aetna of CA Government/Medicare	$135.00
Rate for Payer: Cash Price	$101.25
Rate for Payer: Health Smart Auto/Commercial	$135.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$135.00
Rate for Payer: LLUH Dept of Risk Management WC	$123.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$168.75

HC PHENOBARBITAL (LUMINAL)

Facility

$50.00

Service Code	CPT 80184
Hospital Charge Code	900910409
Hospital Revenue Code	301
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$37.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.00
Rate for Payer: Aetna of CA Government/Medicare	$30.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC PHENOBARBITAL (LUMINAL)

Facility

$190.00

Service Code	CPT 80184
Hospital Charge Code	900910409
Hospital Revenue Code	301
Min. Negotiated Rate	$104.50
Max. Negotiated Rate	$152.00
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna of CA HMO/PPO	$152.00
Rate for Payer: Health Smart Auto/Commercial	$114.00
Rate for Payer: LLUH Dept of Risk Management WC	$104.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$142.50

HC PHENYTOIN (DILANTN)

Facility

$50.00

Service Code	CPT 80185
Hospital Charge Code	900910400
Hospital Revenue Code	301
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$37.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.00
Rate for Payer: Aetna of CA Government/Medicare	$30.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC PHENYTOIN (DILANTN)

Facility

$232.00

Service Code	CPT 80185
Hospital Charge Code	900910400
Hospital Revenue Code	301
Min. Negotiated Rate	$127.60
Max. Negotiated Rate	$185.60
Rate for Payer: Cash Price	$104.40
Rate for Payer: Cigna of CA HMO/PPO	$185.60
Rate for Payer: Health Smart Auto/Commercial	$139.20
Rate for Payer: LLUH Dept of Risk Management WC	$127.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$174.00

HC PHOSPHATIDYLGLYCEROL (PG)

Facility

$63.00

Service Code	CPT 84081
Hospital Charge Code	900910939
Hospital Revenue Code	301
Min. Negotiated Rate	$34.65
Max. Negotiated Rate	$47.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$37.80
Rate for Payer: Aetna of CA Government/Medicare	$37.80
Rate for Payer: Cash Price	$28.35
Rate for Payer: Health Smart Auto/Commercial	$37.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$37.80
Rate for Payer: LLUH Dept of Risk Management WC	$34.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$47.25

HC PHOSPHATIDYLGLYCEROL (PG)

Facility

$230.00

Service Code	CPT 84081
Hospital Charge Code	900910939
Hospital Revenue Code	301
Min. Negotiated Rate	$126.50
Max. Negotiated Rate	$184.00
Rate for Payer: Cash Price	$103.50
Rate for Payer: Cigna of CA HMO/PPO	$184.00
Rate for Payer: Health Smart Auto/Commercial	$138.00
Rate for Payer: LLUH Dept of Risk Management WC	$126.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$172.50

HC PHOSPHOROUS URINE

Facility

$98.00

Service Code	CPT 84105
Hospital Charge Code	900910215
Hospital Revenue Code	301
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$78.40
Rate for Payer: Cash Price	$44.10
Rate for Payer: Cigna of CA HMO/PPO	$78.40
Rate for Payer: Health Smart Auto/Commercial	$58.80
Rate for Payer: LLUH Dept of Risk Management WC	$53.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$73.50

Know your out-of-pocket cost for care.

All Charges