Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM FISH UROTHELIAL CANCER

Facility

$440.00

Service Code	CPT 88120
Hospital Charge Code	900910694
Hospital Revenue Code	310
Min. Negotiated Rate	$242.00
Max. Negotiated Rate	$352.00
Rate for Payer: Cash Price	$440.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$352.00
Rate for Payer: Health Smart Auto/Commercial	$264.00
Rate for Payer: LLUH Dept of Risk Management WC	$242.00
Rate for Payer: Multiplan Commercial	$330.00

HC SOM FISH UROTHELIAL CANCER

Facility

$440.00

Service Code	CPT 88120
Hospital Charge Code	900910694
Hospital Revenue Code	310
Min. Negotiated Rate	$242.00
Max. Negotiated Rate	$352.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$264.00
Rate for Payer: Aetna of CA Government/Medicare	$264.00
Rate for Payer: Cash Price	$440.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$352.00
Rate for Payer: Health Smart Auto/Commercial	$264.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$264.00
Rate for Payer: LLUH Dept of Risk Management WC	$242.00
Rate for Payer: Multiplan Commercial	$330.00

HC SOM FLECAINIDE ACETATE

Facility

$50.00

Service Code	CPT 80181
Hospital Charge Code	900910551
Hospital Revenue Code	301
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$40.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Commercial	$37.50

HC SOM FLECAINIDE ACETATE

Facility

$50.00

Service Code	CPT 80181
Hospital Charge Code	900910551
Hospital Revenue Code	301
Min. Negotiated Rate	$18.64
Max. Negotiated Rate	$40.00
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	$50.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Intervalley Health Plan Commercial	$18.64
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 Commercial	$37.50

HC SOM FLEXERIL

Facility

$69.57

Service Code	CPT 80369
Hospital Charge Code	900911448
Hospital Revenue Code	301
Min. Negotiated Rate	$38.26
Max. Negotiated Rate	$55.66
Rate for Payer: Cash Price	$69.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$55.66
Rate for Payer: Health Smart Auto/Commercial	$41.74
Rate for Payer: LLUH Dept of Risk Management WC	$38.26
Rate for Payer: Multiplan Commercial	$52.18

HC SOM FLEXERIL

Facility

$69.57

Service Code	CPT 80369
Hospital Charge Code	900911448
Hospital Revenue Code	301
Min. Negotiated Rate	$38.26
Max. Negotiated Rate	$55.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$41.74
Rate for Payer: Aetna of CA Government/Medicare	$41.74
Rate for Payer: Cash Price	$69.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$55.66
Rate for Payer: Health Smart Auto/Commercial	$41.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$41.74
Rate for Payer: LLUH Dept of Risk Management WC	$38.26
Rate for Payer: Multiplan Commercial	$52.18

HC SOM FLT3 D835 INTERP

Facility

$162.50

Service Code	CPT 87077
Hospital Charge Code	900914513
Hospital Revenue Code	309
Min. Negotiated Rate	$89.38
Max. Negotiated Rate	$130.00
Rate for Payer: Cash Price	$162.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$130.00
Rate for Payer: Health Smart Auto/Commercial	$97.50
Rate for Payer: LLUH Dept of Risk Management WC	$89.38
Rate for Payer: Multiplan Commercial	$121.88

HC SOM FLT3 D835 INTERP

Facility

$162.50

Service Code	CPT 87077
Hospital Charge Code	900914513
Hospital Revenue Code	309
Min. Negotiated Rate	$8.08
Max. Negotiated Rate	$130.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$97.50
Rate for Payer: Aetna of CA Government/Medicare	$97.50
Rate for Payer: Cash Price	$162.50
Rate for Payer: Cash Price	$162.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$130.00
Rate for Payer: Health Smart Auto/Commercial	$97.50
Rate for Payer: Intervalley Health Plan Commercial	$8.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$97.50
Rate for Payer: LLUH Dept of Risk Management WC	$89.38
Rate for Payer: Multiplan Commercial	$121.88

HC SOM FLT 3 & D835 VARIANT DET

Facility

$165.00

Service Code	CPT 81245
Hospital Charge Code	900912984
Hospital Revenue Code	309
Min. Negotiated Rate	$90.75
Max. Negotiated Rate	$165.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$99.00
Rate for Payer: Aetna of CA Government/Medicare	$99.00
Rate for Payer: Cash Price	$165.00
Rate for Payer: Cash Price	$165.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$132.00
Rate for Payer: Health Smart Auto/Commercial	$99.00
Rate for Payer: Intervalley Health Plan Commercial	$165.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$99.00
Rate for Payer: LLUH Dept of Risk Management WC	$90.75
Rate for Payer: Multiplan Commercial	$123.75

HC SOM FLT 3 & D835 VARIANT DET

Facility

$165.00

Service Code	CPT 81245
Hospital Charge Code	900912984
Hospital Revenue Code	309
Min. Negotiated Rate	$90.75
Max. Negotiated Rate	$132.00
Rate for Payer: Cash Price	$165.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$132.00
Rate for Payer: Health Smart Auto/Commercial	$99.00
Rate for Payer: LLUH Dept of Risk Management WC	$90.75
Rate for Payer: Multiplan Commercial	$123.75

HC SOM FLUORIDE BLOOD

Facility

$263.80

Service Code	CPT 82735
Hospital Charge Code	900911276
Hospital Revenue Code	301
Min. Negotiated Rate	$145.09
Max. Negotiated Rate	$211.04
Rate for Payer: Cash Price	$263.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$211.04
Rate for Payer: Health Smart Auto/Commercial	$158.28
Rate for Payer: LLUH Dept of Risk Management WC	$145.09
Rate for Payer: Multiplan Commercial	$197.85

HC SOM FLUORIDE BLOOD

Facility

$263.80

Service Code	CPT 82735
Hospital Charge Code	900911276
Hospital Revenue Code	301
Min. Negotiated Rate	$18.54
Max. Negotiated Rate	$211.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$158.28
Rate for Payer: Aetna of CA Government/Medicare	$158.28
Rate for Payer: Cash Price	$263.80
Rate for Payer: Cash Price	$263.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$211.04
Rate for Payer: Health Smart Auto/Commercial	$158.28
Rate for Payer: Intervalley Health Plan Commercial	$18.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$158.28
Rate for Payer: LLUH Dept of Risk Management WC	$145.09
Rate for Payer: Multiplan Commercial	$197.85

HC SOM FLUOXETINE

Facility

$55.00

Service Code	CPT 80299
Hospital Charge Code	900911433
Hospital Revenue Code	301
Min. Negotiated Rate	$18.64
Max. Negotiated Rate	$44.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.00
Rate for Payer: Aetna of CA Government/Medicare	$33.00
Rate for Payer: Cash Price	$55.00
Rate for Payer: Cash Price	$55.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.00
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: Intervalley Health Plan Commercial	$18.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.00
Rate for Payer: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Commercial	$41.25

HC SOM FLUOXETINE

Facility

$55.00

Service Code	CPT 80299
Hospital Charge Code	900911433
Hospital Revenue Code	301
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$44.00
Rate for Payer: Cash Price	$55.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.00
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Commercial	$41.25

HC SOM FLUPHENAZINE

Facility

$85.63

Service Code	CPT 80342
Hospital Charge Code	900911432
Hospital Revenue Code	301
Min. Negotiated Rate	$47.10
Max. Negotiated Rate	$68.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.38
Rate for Payer: Aetna of CA Government/Medicare	$51.38
Rate for Payer: Cash Price	$85.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.50
Rate for Payer: Health Smart Auto/Commercial	$51.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.38
Rate for Payer: LLUH Dept of Risk Management WC	$47.10
Rate for Payer: Multiplan Commercial	$64.22

HC SOM FLUPHENAZINE

Facility

$85.63

Service Code	CPT 80342
Hospital Charge Code	900911432
Hospital Revenue Code	301
Min. Negotiated Rate	$47.10
Max. Negotiated Rate	$68.50
Rate for Payer: Cash Price	$85.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.50
Rate for Payer: Health Smart Auto/Commercial	$51.38
Rate for Payer: LLUH Dept of Risk Management WC	$47.10
Rate for Payer: Multiplan Commercial	$64.22

HC SOM FLURAZEPAM (DALMANE) LEVEL

Facility

$67.52

Service Code	CPT 80346
Hospital Charge Code	900911084
Hospital Revenue Code	301
Min. Negotiated Rate	$37.14
Max. Negotiated Rate	$54.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.51
Rate for Payer: Aetna of CA Government/Medicare	$40.51
Rate for Payer: Cash Price	$67.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$54.02
Rate for Payer: Health Smart Auto/Commercial	$40.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.51
Rate for Payer: LLUH Dept of Risk Management WC	$37.14
Rate for Payer: Multiplan Commercial	$50.64

HC SOM FLURAZEPAM (DALMANE) LEVEL

Facility

$67.52

Service Code	CPT 80346
Hospital Charge Code	900911084
Hospital Revenue Code	301
Min. Negotiated Rate	$37.14
Max. Negotiated Rate	$54.02
Rate for Payer: Cash Price	$67.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$54.02
Rate for Payer: Health Smart Auto/Commercial	$40.51
Rate for Payer: LLUH Dept of Risk Management WC	$37.14
Rate for Payer: Multiplan Commercial	$50.64

HC SOM FMIS 83520

Facility

$177.73

Service Code	CPT 83520
Hospital Charge Code	900914924
Hospital Revenue Code	301
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$142.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$106.64
Rate for Payer: Aetna of CA Government/Medicare	$106.64
Rate for Payer: Cash Price	$177.73
Rate for Payer: Cash Price	$177.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$142.18
Rate for Payer: Health Smart Auto/Commercial	$106.64
Rate for Payer: Intervalley Health Plan Commercial	$17.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$106.64
Rate for Payer: LLUH Dept of Risk Management WC	$97.75
Rate for Payer: Multiplan Commercial	$133.30

HC SOM FMIS 83520

Facility

$177.73

Service Code	CPT 83520
Hospital Charge Code	900914924
Hospital Revenue Code	301
Min. Negotiated Rate	$97.75
Max. Negotiated Rate	$142.18
Rate for Payer: Cash Price	$177.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$142.18
Rate for Payer: Health Smart Auto/Commercial	$106.64
Rate for Payer: LLUH Dept of Risk Management WC	$97.75
Rate for Payer: Multiplan Commercial	$133.30

HC SOM FNTSM

Facility

$175.00

Service Code	CPT 82542
Hospital Charge Code	900914870
Hospital Revenue Code	301
Min. Negotiated Rate	$24.09
Max. Negotiated Rate	$140.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$105.00
Rate for Payer: Aetna of CA Government/Medicare	$105.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: Intervalley Health Plan Commercial	$24.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Commercial	$131.25

HC SOM FNTSM

Facility

$175.00

Service Code	CPT 82542
Hospital Charge Code	900914870
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$140.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Commercial	$131.25

HC SOM FNTSM 82492A

Facility

$175.00

Service Code	CPT 82542
Hospital Charge Code	900914868
Hospital Revenue Code	301
Min. Negotiated Rate	$24.09
Max. Negotiated Rate	$140.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$105.00
Rate for Payer: Aetna of CA Government/Medicare	$105.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: Intervalley Health Plan Commercial	$24.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Commercial	$131.25

HC SOM FNTSM 82492A

Facility

$175.00

Service Code	CPT 82542
Hospital Charge Code	900914868
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$140.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Commercial	$131.25

HC SOM FNTSM 82492B

Facility

$175.00

Service Code	CPT 82542
Hospital Charge Code	900914869
Hospital Revenue Code	301
Min. Negotiated Rate	$24.09
Max. Negotiated Rate	$140.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$105.00
Rate for Payer: Aetna of CA Government/Medicare	$105.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: Intervalley Health Plan Commercial	$24.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Commercial	$131.25

Know your out-of-pocket cost for care.

All Charges