Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOCIDEM PDC 84999

Facility

$120.00

Service Code	CPT 84999
Hospital Charge Code	900915253
Hospital Revenue Code	309
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$72.00
Rate for Payer: Aetna of CA Government/Medicare	$72.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$72.00
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.00

HC SOCIDEM PDC 84999

Facility

$120.00

Service Code	CPT 84999
Hospital Charge Code	900915253
Hospital Revenue Code	309
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$96.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna of CA HMO/PPO	$96.00
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.00

HC SOCIDEM PDC 84999

Facility

$120.00

Service Code	CPT 84999 90
Hospital Charge Code	900915253
Hospital Revenue Code	300
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$72.00
Rate for Payer: Aetna of CA Government/Medicare	$72.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$72.00
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.00

HC SODIUM

Facility

$89.00

Service Code	CPT 84295
Hospital Charge Code	900910269
Hospital Revenue Code	301
Min. Negotiated Rate	$48.95
Max. Negotiated Rate	$71.20
Rate for Payer: Cash Price	$40.05
Rate for Payer: Cigna of CA HMO/PPO	$71.20
Rate for Payer: Health Smart Auto/Commercial	$53.40
Rate for Payer: LLUH Dept of Risk Management WC	$48.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$66.75

HC SODIUM

Facility

$15.00

Service Code	CPT 84295
Hospital Charge Code	900910269
Hospital Revenue Code	301
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$11.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.00
Rate for Payer: Aetna of CA Government/Medicare	$9.00
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.25

HC SODIUM BODY FLUID

Facility

$25.00

Service Code	CPT 84302
Hospital Charge Code	900912246
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Cigna of CA HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

HC SODIUM BODY FLUID

Facility

$17.00

Service Code	CPT 84302
Hospital Charge Code	900912246
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 SODIUM STOOL

Facility

$179.00

Service Code	CPT 84302
Hospital Charge Code	900910418
Hospital Revenue Code	301
Min. Negotiated Rate	$98.45
Max. Negotiated Rate	$143.20
Rate for Payer: Cash Price	$80.55
Rate for Payer: Cigna of CA HMO/PPO	$143.20
Rate for Payer: Health Smart Auto/Commercial	$107.40
Rate for Payer: LLUH Dept of Risk Management WC	$98.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$134.25

HC SODIUM STOOL

Facility

$16.00

Service Code	CPT 84302
Hospital Charge Code	900910418
Hospital Revenue Code	301
Min. Negotiated Rate	$8.80
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.60
Rate for Payer: Aetna of CA Government/Medicare	$9.60
Rate for Payer: Cash Price	$7.20
Rate for Payer: Health Smart Auto/Commercial	$9.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.60
Rate for Payer: LLUH Dept of Risk Management WC	$8.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.00

HC SODIUM URINE

Facility

$100.00

Service Code	CPT 84300
Hospital Charge Code	900910270
Hospital Revenue Code	301
Min. Negotiated Rate	$55.00
Max. Negotiated Rate	$80.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cigna of CA HMO/PPO	$80.00
Rate for Payer: Health Smart Auto/Commercial	$60.00
Rate for Payer: LLUH Dept of Risk Management WC	$55.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.00

HC SODIUM URINE

Facility

$15.00

Service Code	CPT 84300
Hospital Charge Code	900910270
Hospital Revenue Code	301
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$11.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.00
Rate for Payer: Aetna of CA Government/Medicare	$9.00
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.25

HC SOF 60735 MYCOP IGG 86738

Facility

$65.04

Service Code	CPT 86738 90
Hospital Charge Code	900914877
Hospital Revenue Code	302
Min. Negotiated Rate	$35.77
Max. Negotiated Rate	$48.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.02
Rate for Payer: Aetna of CA Government/Medicare	$39.02
Rate for Payer: Cash Price	$29.27
Rate for Payer: Health Smart Auto/Commercial	$39.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.02
Rate for Payer: LLUH Dept of Risk Management WC	$35.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$48.78

HC SOF 60735 MYCOP IGG 86738

Facility

$65.04

Service Code	CPT 86738 90
Hospital Charge Code	900914877
Hospital Revenue Code	302
Min. Negotiated Rate	$35.77
Max. Negotiated Rate	$52.03
Rate for Payer: Cash Price	$29.27
Rate for Payer: Cigna of CA HMO/PPO	$52.03
Rate for Payer: Health Smart Auto/Commercial	$39.02
Rate for Payer: LLUH Dept of Risk Management WC	$35.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$48.78

HC SOF 60735 MYCOP IGG 86738

Facility

$65.04

Service Code	CPT 86738
Hospital Charge Code	900914877
Hospital Revenue Code	302
Min. Negotiated Rate	$35.77
Max. Negotiated Rate	$48.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.02
Rate for Payer: Aetna of CA Government/Medicare	$39.02
Rate for Payer: Cash Price	$29.27
Rate for Payer: Health Smart Auto/Commercial	$39.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.02
Rate for Payer: LLUH Dept of Risk Management WC	$35.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$48.78

HC SOF 60735 MYCOP IGG 86738

Facility

$65.04

Service Code	CPT 86738
Hospital Charge Code	900914877
Hospital Revenue Code	302
Min. Negotiated Rate	$35.77
Max. Negotiated Rate	$52.03
Rate for Payer: Cash Price	$29.27
Rate for Payer: Cigna of CA HMO/PPO	$52.03
Rate for Payer: Health Smart Auto/Commercial	$39.02
Rate for Payer: LLUH Dept of Risk Management WC	$35.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$48.78

HC SOF 60735 MYCOP IGM 86738

Facility

$65.04

Service Code	CPT 86738
Hospital Charge Code	900914878
Hospital Revenue Code	302
Min. Negotiated Rate	$35.77
Max. Negotiated Rate	$52.03
Rate for Payer: Cash Price	$29.27
Rate for Payer: Cigna of CA HMO/PPO	$52.03
Rate for Payer: Health Smart Auto/Commercial	$39.02
Rate for Payer: LLUH Dept of Risk Management WC	$35.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$48.78

HC SOF 60735 MYCOP IGM 86738

Facility

$65.04

Service Code	CPT 86738 90
Hospital Charge Code	900914878
Hospital Revenue Code	302
Min. Negotiated Rate	$35.77
Max. Negotiated Rate	$48.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.02
Rate for Payer: Aetna of CA Government/Medicare	$39.02
Rate for Payer: Cash Price	$29.27
Rate for Payer: Health Smart Auto/Commercial	$39.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.02
Rate for Payer: LLUH Dept of Risk Management WC	$35.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$48.78

HC SOF 60735 MYCOP IGM 86738

Facility

$65.04

Service Code	CPT 86738
Hospital Charge Code	900914878
Hospital Revenue Code	302
Min. Negotiated Rate	$35.77
Max. Negotiated Rate	$48.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.02
Rate for Payer: Aetna of CA Government/Medicare	$39.02
Rate for Payer: Cash Price	$29.27
Rate for Payer: Health Smart Auto/Commercial	$39.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.02
Rate for Payer: LLUH Dept of Risk Management WC	$35.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$48.78

HC SOF 60735 MYCOP IGM 86738

Facility

$65.04

Service Code	CPT 86738 90
Hospital Charge Code	900914878
Hospital Revenue Code	302
Min. Negotiated Rate	$35.77
Max. Negotiated Rate	$52.03
Rate for Payer: Cash Price	$29.27
Rate for Payer: Cigna of CA HMO/PPO	$52.03
Rate for Payer: Health Smart Auto/Commercial	$39.02
Rate for Payer: LLUH Dept of Risk Management WC	$35.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$48.78

HC SOF ADENOVIRUS DNA QUANT PCR

Facility

$349.00

Service Code	CPT 87799 90
Hospital Charge Code	900912932
Hospital Revenue Code	306
Min. Negotiated Rate	$191.95
Max. Negotiated Rate	$279.20
Rate for Payer: Cash Price	$157.05
Rate for Payer: Cigna of CA HMO/PPO	$279.20
Rate for Payer: Health Smart Auto/Commercial	$209.40
Rate for Payer: LLUH Dept of Risk Management WC	$191.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$261.75

HC SOF ADENOVIRUS DNA QUANT PCR

Facility

$349.00

Service Code	CPT 87799 90
Hospital Charge Code	900912932
Hospital Revenue Code	306
Min. Negotiated Rate	$191.95
Max. Negotiated Rate	$261.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$209.40
Rate for Payer: Aetna of CA Government/Medicare	$209.40
Rate for Payer: Cash Price	$157.05
Rate for Payer: Health Smart Auto/Commercial	$209.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$209.40
Rate for Payer: LLUH Dept of Risk Management WC	$191.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$261.75

HC SOF ADENOVIRUS DNA QUANT PCR

Facility

$349.00

Service Code	CPT 87799
Hospital Charge Code	900912932
Hospital Revenue Code	306
Min. Negotiated Rate	$191.95
Max. Negotiated Rate	$279.20
Rate for Payer: Cash Price	$157.05
Rate for Payer: Cigna of CA HMO/PPO	$279.20
Rate for Payer: Health Smart Auto/Commercial	$209.40
Rate for Payer: LLUH Dept of Risk Management WC	$191.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$261.75

HC SOF ADENOVIRUS DNA QUANT PCR

Facility

$349.00

Service Code	CPT 87799
Hospital Charge Code	900912932
Hospital Revenue Code	306
Min. Negotiated Rate	$191.95
Max. Negotiated Rate	$261.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$209.40
Rate for Payer: Aetna of CA Government/Medicare	$209.40
Rate for Payer: Cash Price	$157.05
Rate for Payer: Health Smart Auto/Commercial	$209.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$209.40
Rate for Payer: LLUH Dept of Risk Management WC	$191.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$261.75

HC SOGDX 230 GCH1 81479

Facility

$925.00

Service Code	CPT 81479
Hospital Charge Code	900914803
Hospital Revenue Code	309
Min. Negotiated Rate	$508.75
Max. Negotiated Rate	$740.00
Rate for Payer: Cash Price	$416.25
Rate for Payer: Cigna of CA HMO/PPO	$740.00
Rate for Payer: Health Smart Auto/Commercial	$555.00
Rate for Payer: LLUH Dept of Risk Management WC	$508.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$693.75

HC SOGDX 230 GCH1 81479

Facility

$925.00

Service Code	CPT 81479 90
Hospital Charge Code	900914803
Hospital Revenue Code	300
Min. Negotiated Rate	$508.75
Max. Negotiated Rate	$693.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$555.00
Rate for Payer: Aetna of CA Government/Medicare	$555.00
Rate for Payer: Cash Price	$416.25
Rate for Payer: Health Smart Auto/Commercial	$555.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$555.00
Rate for Payer: LLUH Dept of Risk Management WC	$508.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$693.75

Know your out-of-pocket cost for care.

All Charges