Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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	$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 317 SIX1 81479

Facility

$675.00

Service Code	CPT 81479
Hospital Charge Code	900914808
Hospital Revenue Code	309
Min. Negotiated Rate	$371.25
Max. Negotiated Rate	$540.00
Rate for Payer: Cash Price	$303.75
Rate for Payer: Cigna of CA HMO/PPO	$540.00
Rate for Payer: Health Smart Auto/Commercial	$405.00
Rate for Payer: LLUH Dept of Risk Management WC	$371.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$506.25

HC SOGDX 317 SIX1 81479

Facility

$675.00

Service Code	CPT 81479 90
Hospital Charge Code	900914808
Hospital Revenue Code	300
Min. Negotiated Rate	$371.25
Max. Negotiated Rate	$540.00
Rate for Payer: Cash Price	$303.75
Rate for Payer: Cigna of CA HMO/PPO	$540.00
Rate for Payer: Health Smart Auto/Commercial	$405.00
Rate for Payer: LLUH Dept of Risk Management WC	$371.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$506.25

HC SOGDX 317 SIX1 81479

Facility

$675.00

Service Code	CPT 81479
Hospital Charge Code	900914808
Hospital Revenue Code	309
Min. Negotiated Rate	$371.25
Max. Negotiated Rate	$506.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$405.00
Rate for Payer: Aetna of CA Government/Medicare	$405.00
Rate for Payer: Cash Price	$303.75
Rate for Payer: Health Smart Auto/Commercial	$405.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$405.00
Rate for Payer: LLUH Dept of Risk Management WC	$371.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$506.25

HC SOGDX 317 SIX1 81479

Facility

$675.00

Service Code	CPT 81479 90
Hospital Charge Code	900914808
Hospital Revenue Code	300
Min. Negotiated Rate	$371.25
Max. Negotiated Rate	$506.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$405.00
Rate for Payer: Aetna of CA Government/Medicare	$405.00
Rate for Payer: Cash Price	$303.75
Rate for Payer: Health Smart Auto/Commercial	$405.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$405.00
Rate for Payer: LLUH Dept of Risk Management WC	$371.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$506.25

HC SOGDX 559 TP53 GENE 81405

Facility

$1,395.00

Service Code	CPT 81405
Hospital Charge Code	900914849
Hospital Revenue Code	309
Min. Negotiated Rate	$767.25
Max. Negotiated Rate	$1,116.00
Rate for Payer: Cash Price	$627.75
Rate for Payer: Cigna of CA HMO/PPO	$1,116.00
Rate for Payer: Health Smart Auto/Commercial	$837.00
Rate for Payer: LLUH Dept of Risk Management WC	$767.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,046.25

HC SOGDX 559 TP53 GENE 81405

Facility

$1,395.00

Service Code	CPT 81405 90
Hospital Charge Code	900914849
Hospital Revenue Code	310
Min. Negotiated Rate	$767.25
Max. Negotiated Rate	$1,116.00
Rate for Payer: Cash Price	$627.75
Rate for Payer: Cigna of CA HMO/PPO	$1,116.00
Rate for Payer: Health Smart Auto/Commercial	$837.00
Rate for Payer: LLUH Dept of Risk Management WC	$767.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,046.25

HC SOGDX 559 TP53 GENE 81405

Facility

$1,395.00

Service Code	CPT 81405
Hospital Charge Code	900914849
Hospital Revenue Code	309
Min. Negotiated Rate	$767.25
Max. Negotiated Rate	$1,046.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$837.00
Rate for Payer: Aetna of CA Government/Medicare	$837.00
Rate for Payer: Cash Price	$627.75
Rate for Payer: Health Smart Auto/Commercial	$837.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$837.00
Rate for Payer: LLUH Dept of Risk Management WC	$767.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,046.25

HC SOGDX 559 TP53 GENE 81405

Facility

$1,395.00

Service Code	CPT 81405 90
Hospital Charge Code	900914849
Hospital Revenue Code	310
Min. Negotiated Rate	$767.25
Max. Negotiated Rate	$1,046.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$837.00
Rate for Payer: Aetna of CA Government/Medicare	$837.00
Rate for Payer: Cash Price	$627.75
Rate for Payer: Health Smart Auto/Commercial	$837.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$837.00
Rate for Payer: LLUH Dept of Risk Management WC	$767.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,046.25

HC SOLUBLE FIBRIN

Facility

$121.00

Service Code	CPT 85366
Hospital Charge Code	900910118
Hospital Revenue Code	305
Min. Negotiated Rate	$66.55
Max. Negotiated Rate	$96.80
Rate for Payer: Cash Price	$54.45
Rate for Payer: Cigna of CA HMO/PPO	$96.80
Rate for Payer: Health Smart Auto/Commercial	$72.60
Rate for Payer: LLUH Dept of Risk Management WC	$66.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.75

HC SOLUBLE FIBRIN

Facility

$85.00

Service Code	CPT 85366
Hospital Charge Code	900910118
Hospital Revenue Code	305
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$63.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.00
Rate for Payer: Aetna of CA Government/Medicare	$51.00
Rate for Payer: Cash Price	$38.25
Rate for Payer: Health Smart Auto/Commercial	$51.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.00
Rate for Payer: LLUH Dept of Risk Management WC	$46.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$63.75

HC SOM 11-DEOXYCORTISOL (COMPOUNDS)

Facility

$120.00

Service Code	CPT 82633
Hospital Charge Code	900911027
Hospital Revenue Code	301
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 SOM 11-DEOXYCORTISOL (COMPOUNDS)

Facility

$120.00

Service Code	CPT 82633 90
Hospital Charge Code	900911027
Hospital Revenue Code	301
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 SOM 11-DEOXYCORTISOL (COMPOUNDS)

Facility

$120.00

Service Code	CPT 82633 90
Hospital Charge Code	900911027
Hospital Revenue Code	301
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 SOM 11-DEOXYCORTISOL (COMPOUNDS)

Facility

$120.00

Service Code	CPT 82633
Hospital Charge Code	900911027
Hospital Revenue Code	301
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 SOM 17-OH-PROGESTERONE

Facility

$17.55

Service Code	CPT 83498
Hospital Charge Code	900911017
Hospital Revenue Code	301
Min. Negotiated Rate	$9.65
Max. Negotiated Rate	$13.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.53
Rate for Payer: Aetna of CA Government/Medicare	$10.53
Rate for Payer: Cash Price	$7.90
Rate for Payer: Health Smart Auto/Commercial	$10.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.53
Rate for Payer: LLUH Dept of Risk Management WC	$9.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.16

HC SOM 17-OH-PROGESTERONE

Facility

$17.55

Service Code	CPT 83498
Hospital Charge Code	900911017
Hospital Revenue Code	301
Min. Negotiated Rate	$9.65
Max. Negotiated Rate	$14.04
Rate for Payer: Cash Price	$7.90
Rate for Payer: Cigna of CA HMO/PPO	$14.04
Rate for Payer: Health Smart Auto/Commercial	$10.53
Rate for Payer: LLUH Dept of Risk Management WC	$9.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.16

HC SOM 17-OH-PROGESTERONE

Facility

$17.55

Service Code	CPT 83498 90
Hospital Charge Code	900911017
Hospital Revenue Code	301
Min. Negotiated Rate	$9.65
Max. Negotiated Rate	$13.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.53
Rate for Payer: Aetna of CA Government/Medicare	$10.53
Rate for Payer: Cash Price	$7.90
Rate for Payer: Health Smart Auto/Commercial	$10.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.53
Rate for Payer: LLUH Dept of Risk Management WC	$9.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.16

HC SOM 17-OH-PROGESTERONE

Facility

$17.55

Service Code	CPT 83498 90
Hospital Charge Code	900911017
Hospital Revenue Code	301
Min. Negotiated Rate	$9.65
Max. Negotiated Rate	$14.04
Rate for Payer: Cash Price	$7.90
Rate for Payer: Cigna of CA HMO/PPO	$14.04
Rate for Payer: Health Smart Auto/Commercial	$10.53
Rate for Payer: LLUH Dept of Risk Management WC	$9.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.16

HC SOM 18-OH CORTICOSTERONE

Facility

$169.00

Service Code	CPT 82542
Hospital Charge Code	900910709
Hospital Revenue Code	301
Min. Negotiated Rate	$92.95
Max. Negotiated Rate	$135.20
Rate for Payer: Cash Price	$76.05
Rate for Payer: Cigna of CA HMO/PPO	$135.20
Rate for Payer: Health Smart Auto/Commercial	$101.40
Rate for Payer: LLUH Dept of Risk Management WC	$92.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$126.75

HC SOM 18-OH CORTICOSTERONE

Facility

$169.00

Service Code	CPT 82542 90
Hospital Charge Code	900910709
Hospital Revenue Code	301
Min. Negotiated Rate	$92.95
Max. Negotiated Rate	$126.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$101.40
Rate for Payer: Aetna of CA Government/Medicare	$101.40
Rate for Payer: Cash Price	$76.05
Rate for Payer: Health Smart Auto/Commercial	$101.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$101.40
Rate for Payer: LLUH Dept of Risk Management WC	$92.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$126.75

HC SOM 18-OH CORTICOSTERONE

Facility

$169.00

Service Code	CPT 82542 90
Hospital Charge Code	900910709
Hospital Revenue Code	301
Min. Negotiated Rate	$92.95
Max. Negotiated Rate	$135.20
Rate for Payer: Cash Price	$76.05
Rate for Payer: Cigna of CA HMO/PPO	$135.20
Rate for Payer: Health Smart Auto/Commercial	$101.40
Rate for Payer: LLUH Dept of Risk Management WC	$92.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$126.75

HC SOM 18-OH CORTICOSTERONE

Facility

$169.00

Service Code	CPT 82542
Hospital Charge Code	900910709
Hospital Revenue Code	301
Min. Negotiated Rate	$92.95
Max. Negotiated Rate	$126.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$101.40
Rate for Payer: Aetna of CA Government/Medicare	$101.40
Rate for Payer: Cash Price	$76.05
Rate for Payer: Health Smart Auto/Commercial	$101.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$101.40
Rate for Payer: LLUH Dept of Risk Management WC	$92.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$126.75

HC SOM 199PC 86301

Facility

$29.81

Service Code	CPT 86301 90
Hospital Charge Code	900914879
Hospital Revenue Code	301
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$22.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.89
Rate for Payer: Aetna of CA Government/Medicare	$17.89
Rate for Payer: Cash Price	$13.41
Rate for Payer: Health Smart Auto/Commercial	$17.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.89
Rate for Payer: LLUH Dept of Risk Management WC	$16.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.36

Know your out-of-pocket cost for care.

All Charges